Provider Demographics
NPI:1306285598
Name:MOEAI, MICAH (MS, ATC)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:MOEAI
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 HOSPITAL WAY
Mailing Address - Street 2:BLD D, STE 100
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5091
Mailing Address - Country:US
Mailing Address - Phone:208-239-8010
Mailing Address - Fax:
Practice Address - Street 1:1151 HOSPITAL WAY, BLD D, STE 100
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202
Practice Address - Country:US
Practice Address - Phone:808-277-3706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8706704-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer