Provider Demographics
NPI:1164063368
Name:VAZALES, KIIRA (PA)
Entity Type:Individual
Prefix:
First Name:KIIRA
Middle Name:
Last Name:VAZALES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8854 W EMERALD ST STE 102
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4845
Mailing Address - Country:US
Mailing Address - Phone:208-323-4747
Mailing Address - Fax:
Practice Address - Street 1:8854 W EMERALD ST STE 102
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4845
Practice Address - Country:US
Practice Address - Phone:208-323-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA1796207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery