Provider Demographics
NPI:1669792859
Name:MILLIRON, ANASTASIA BROOKE (NPC)
Entity type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:BROOKE
Last Name:MILLIRON
Suffix:
Gender:F
Credentials:NPC
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:MILLIRON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4521 THOMAS JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-5100
Mailing Address - Country:US
Mailing Address - Phone:208-454-4820
Mailing Address - Fax:
Practice Address - Street 1:4521 THOMAS JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605
Practice Address - Country:US
Practice Address - Phone:208-454-4820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP987-A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003399100Medicaid
ID1669792859Medicaid
ID1669792859Medicaid