Basic Information
| Provider Information | |||||||||
| NPI: | 1336156496 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOURZEK | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J | ||||||||
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| NameSuffix: | SR. | ||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3648 | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838162522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082920292 | ||||||||
| FaxNumber: | 2082920705 | ||||||||
| Practice Location | |||||||||
| Address1: | 1090 W PARK PL | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082920292 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 07/14/2016 | ||||||||
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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 | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA10003546 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA-176 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1336156496 | 05 | ID | MEDICAID |