Provider Demographics
NPI:1346734860
Name:THORESON, MICAH (NP)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:THORESON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E PARK BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-7791
Mailing Address - Country:US
Mailing Address - Phone:208-381-4100
Mailing Address - Fax:208-381-4101
Practice Address - Street 1:1000 E PARK BLVD STE 120
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-7791
Practice Address - Country:US
Practice Address - Phone:208-381-4100
Practice Address - Fax:208-381-4101
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID57732363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner