Provider Demographics
NPI:1487904280
Name:NIERAETH, MICHAEL ROBERT (PA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:NIERAETH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8854 W EMERALD ST STE 102
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4845
Mailing Address - Country:US
Mailing Address - Phone:208-323-4747
Mailing Address - Fax:208-323-4848
Practice Address - Street 1:8854 W EMERALD ST STE 102
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-323-4747
Practice Address - Fax:208-323-4848
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-993363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1487904280Medicaid
ID1487904280Medicaid
ID1487904280Medicaid
WAG8915728Medicare PIN