Healthcare Provider Details

I. General information

NPI: 1770346835
Provider Name (Legal Business Name): RILEE WONG MICKELSEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1072 N LIBERTY ST STE 201
BOISE ID
83704-8708
US

IV. Provider business mailing address

PO BOX 190930
BOISE ID
83719-0930
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-2400
  • Fax: 208-302-2455
Mailing address:
  • Phone: 208-367-5170
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA065365
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA065365
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number8061671
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: