Basic Information
| Provider Information | |||||||||
| NPI: | 1962533083 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MYERS | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 587 | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833030587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088147400 | ||||||||
| FaxNumber: | 2088147491 | ||||||||
| Practice Location | |||||||||
| Address1: | 746 N COLLEGE RD | ||||||||
| Address2: | SUITE D | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833013486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088147230 | ||||||||
| FaxNumber: | 2087341178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 01/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | O-0524 | ID | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 808322000 | 05 | ID | MEDICAID | P00809349 | 01 | ID | MCRR | OTHER |