Basic Information
| Provider Information | |||||||||
| NPI: | 1104895275 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIKLOS | ||||||||
| FirstName: | WENDY | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063295746 | ||||||||
| FaxNumber: | 4065418846 | ||||||||
| Practice Location | |||||||||
| Address1: | 2875 TINA AVE STE 104 | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598081582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063295746 | ||||||||
| FaxNumber: | 4065418846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 10404 | MT | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2083P0500X | 10404 | MT | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Preventive Medicine/Occupational Environmental Medicine |
No ID Information.