Basic Information
Provider Information | |||||||||
NPI: | 1447204995 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MIKLES | ||||||||
FirstName: | ERIKA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JUERGENSEN | ||||||||
OtherFirstName: | ERIKA | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 122 W 7TH AVE | ||||||||
Address2: | SUITE 310 | ||||||||
City: | SPOKANE | ||||||||
State: | WA | ||||||||
PostalCode: | 992042349 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5098387711 | ||||||||
FaxNumber: | 5097474664 | ||||||||
Practice Location | |||||||||
Address1: | 1090 W PARK PL | ||||||||
Address2: |   | ||||||||
City: | COEUR D ALENE | ||||||||
State: | ID | ||||||||
PostalCode: | 838142785 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2082152005 | ||||||||
FaxNumber: | 8448073782 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/20/2006 | ||||||||
LastUpdateDate: | 08/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA-586 | ID | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 807347700 | 05 | ID |   | MEDICAID |