Basic Information
| Provider Information | |||||||||
| NPI: | 1639578628 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHAELIS | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3340 E GOLDSTONE WAY | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083020000 | ||||||||
| FaxNumber: | 2083020055 | ||||||||
| Practice Location | |||||||||
| Address1: | 6140 W CURTISIAN AVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083020000 | ||||||||
| FaxNumber: | 2083020055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2014 | ||||||||
| LastUpdateDate: | 02/11/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 9009534-4405 | UT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LG0600X | 60235 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.