Basic Information
| Provider Information | |||||||||
| NPI: | 1033592605 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAHANG | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1550 N CRESTMONT DR | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836422184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082884200 | ||||||||
| FaxNumber: | 2082884279 | ||||||||
| Practice Location | |||||||||
| Address1: | 1550 N CRESTMONT DR | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836422184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082884200 | ||||||||
| FaxNumber: | 2082884279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2015 | ||||||||
| LastUpdateDate: | 01/18/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 54932 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.