Individual
TAI BANTA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
14107 N 5TH E, IDAHO FALLS, ID 83401-5105
(208) 881-7462
Mailing address
14107 N 5TH E, IDAHO FALLS, ID 83401-5105
(208) 881-7462
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
—
ID
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
07/05/2022
Last updated
10/14/2022
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