Provider Demographics
NPI:1376570440
Name:MILLER, JONATHAN B (PA-C)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:B
Last Name:MILLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N LIBERTY ST STE 400
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8707
Mailing Address - Country:US
Mailing Address - Phone:208-367-3320
Mailing Address - Fax:
Practice Address - Street 1:900 N LIBERTY ST STE 400
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8707
Practice Address - Country:US
Practice Address - Phone:208-367-3320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA549363AM0700X
ORPA01356363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010149921OtherREGENCE BLUE SHIELD
IDPA549OtherPA MEDICAL LICENSE
IDPAVQ9OtherBLUE CROSS OF IDAHO
ID807126000Medicaid
ID000010149921OtherREGENCE BLUE SHIELD
ID1666904Medicare ID - Type Unspecified