Healthcare Provider Details

I. General information

NPI: 1083992606
Provider Name (Legal Business Name): YUKIKO MIURA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2011
Last Update Date: 04/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E IDAHO ST
BOISE ID
83712-6267
US

IV. Provider business mailing address

100 E IDAHO ST
BOISE ID
83712-6267
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-2088
  • Fax:
Mailing address:
  • Phone: 208-381-2088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number277988
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberM-14168
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: