MEDICARE: JACESON BANHAM PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	8671842	ID

General Provider Information

NPI Number	:	1295544344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACESON BANHAM PA-C

Provider Business Mailing Address
First Line	:	1957 E 17TH ST
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-6429
Country	:	US
Telephone Number	:	208-523-1100
Fax Number	:

Provider Business Practice Location Address
First Line	:	1957 E 17TH ST
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-6429
Country	:	US
Telephone Number	:	208-523-1100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2025
Last Update Date	:	06/08/2026

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Directions to “ JACESON BANHAM PA-C” Practice Location

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