Provider Demographics
NPI:1710011325
Name:MILES, MICHELE (PA-C,MS)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:
Last Name:MILES
Suffix:
Gender:F
Credentials:PA-C,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 191050
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1050
Mailing Address - Country:US
Mailing Address - Phone:208-955-6500
Mailing Address - Fax:
Practice Address - Street 1:1475 N COLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8537
Practice Address - Country:US
Practice Address - Phone:208-809-2880
Practice Address - Fax:208-809-2881
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDID PA498363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807782300Medicaid
ID807782300Medicaid
ID1344650Medicare PIN
ID13446591Medicare PIN