Healthcare Provider Details

I. General information

NPI: 1346418829
Provider Name (Legal Business Name): WANDRA K. MILES, MD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2008
Last Update Date: 08/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3137 TONGASS AVE
KETCHIKAN AK
99901-5745
US

IV. Provider business mailing address

PO BOX 50150
BELLEVUE WA
98015-0150
US

V. Phone/Fax

Practice location:
  • Phone: 206-292-6226
  • Fax: 206-623-8825
Mailing address:
  • Phone: 425-228-5228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4971
License Number StateAK

VIII. Authorized Official

Name: WANDRA K MILES
Title or Position: OWNER
Credential: MD
Phone: 206-292-6226