Provider Demographics
NPI:1437222528
Name:OSTERMILLER, JEREMY B (PAC)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:B
Last Name:OSTERMILLER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 WARNER DRIVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501
Mailing Address - Country:US
Mailing Address - Phone:208-791-9889
Mailing Address - Fax:
Practice Address - Street 1:320 WARNER DRIVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501
Practice Address - Country:US
Practice Address - Phone:208-791-9889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA435363A00000X
WAPA10004462363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8358517Medicaid
ID000010142606OtherREGENCE
IDPALL2OtherBLUE CROSS OF IDAHO
ID1665088Medicare PIN
IDP00012023Medicare PIN
WAGAB36838Medicare PIN
IDPALL2OtherBLUE CROSS OF IDAHO