Provider Demographics
NPI:1689263865
Name:MYLER, JACOB ALAN (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ALAN
Last Name:MYLER
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 1:422 S SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-4850
Mailing Address - Country:US
Mailing Address - Phone:208-521-1426
Mailing Address - Fax:
Practice Address - Street 1:1050 MYDLAND RD
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2186
Practice Address - Country:US
Practice Address - Phone:307-674-7469
Practice Address - Fax:307-674-4619
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program