Provider Demographics
NPI:1407047202
Name:OSTERMILLER, MARIYA ROSE (MPAS, PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARIYA
Middle Name:ROSE
Last Name:OSTERMILLER
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2535 E FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8072
Mailing Address - Country:US
Mailing Address - Phone:208-519-4333
Mailing Address - Fax:208-205-9134
Practice Address - Street 1:2535 E FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8072
Practice Address - Country:US
Practice Address - Phone:208-519-4333
Practice Address - Fax:208-205-9134
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA 683363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1407047202OtherNPI