Provider Demographics
NPI:1720663644
Name:ILIEFF, MIROSLAV
Entity Type:Individual
Prefix:
First Name:MIROSLAV
Middle Name:
Last Name:ILIEFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 E BASELINE RD STE 204
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2743
Mailing Address - Country:US
Mailing Address - Phone:480-565-6440
Mailing Address - Fax:
Practice Address - Street 1:2438 E IVANHOE CT
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-9021
Practice Address - Country:US
Practice Address - Phone:480-789-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-11
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ252592363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health