Provider Demographics
NPI:1114576774
Name:KOTCHEVAR, MILES GARTH (NP)
Entity Type:Individual
Prefix:
First Name:MILES
Middle Name:GARTH
Last Name:KOTCHEVAR
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 BOXWOOD LN
Mailing Address - Street 2:
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-2679
Mailing Address - Country:US
Mailing Address - Phone:510-207-9671
Mailing Address - Fax:
Practice Address - Street 1:900 BLAKE WILBUR DR
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-2201
Practice Address - Country:US
Practice Address - Phone:650-498-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011978363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner