Healthcare Provider Details

I. General information

NPI: 1649879081
Provider Name (Legal Business Name): GRACE SUYANTI MULIAWAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2020
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 CLINIC RD
CHALLIS ID
83226-4824
US

IV. Provider business mailing address

PO BOX 980
CHALLIS ID
83226-0980
US

V. Phone/Fax

Practice location:
  • Phone: 208-879-4351
  • Fax: 208-879-5216
Mailing address:
  • Phone: 208-879-4351
  • Fax: 208-879-5216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-1991
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1991
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: