Healthcare Provider Details

I. General information

NPI: 1104568237
Provider Name (Legal Business Name): KATYLYNN ANN DIZDAREVIC-MILLER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2022
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 W ST LUKES DR
NAMPA ID
83687-7912
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-463-7300
  • Fax: 208-463-7301
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM17436
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: