Healthcare Provider Details

I. General information

NPI: 1487587481
Provider Name (Legal Business Name): MICHAEL PHILIP ABRACOSA GILLIAM CPNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
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: 208-381-2222
  • Fax:
Mailing address:
  • Phone: 208-861-9365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number5481515
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: