Organization
SOUTHEAST FIRST ASSISTANT LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DREW JOHNSON PAC (OWNER)
(208) 215-6411
Entity
Organization
Contact information
Practice address
12473 E NUNN RD, ATHOL, ID 83801-9311
(208) 215-6411
Mailing address
12473 E NUNN RD, ATHOL, ID 83801-9311
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
PA-1167
ID
363AS0400X
Surgical Physician Assistant
Primary
PA-1167
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PA-1167
IDAHO LICENSE
ID
Enumeration date
11/03/2015
Last updated
11/03/2015
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