Provider Demographics
NPI:1346418829
Name:WANDRA K. MILES, MD, PLLC
Entity Type:Organization
Organization Name:WANDRA K. MILES, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WANDRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-292-6226
Mailing Address - Street 1:PO BOX 50150
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98015-0150
Mailing Address - Country:US
Mailing Address - Phone:425-228-5228
Mailing Address - Fax:
Practice Address - Street 1:3137 TONGASS AVE
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5745
Practice Address - Country:US
Practice Address - Phone:206-292-6226
Practice Address - Fax:206-623-8825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-18
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4971208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKK160240Medicare PIN