Healthcare Provider Details

I. General information

NPI: 1366934564
Provider Name (Legal Business Name): ALEXANDRA MILLER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-1615
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number187661
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberM-17356
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: