Healthcare Provider Details

I. General information

NPI: 1659067304
Provider Name (Legal Business Name): MIRANDA J CROUCH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2023
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 NW LARCH AVE
REDMOND OR
97756-1357
US

IV. Provider business mailing address

777 N RAYMOND ST
BOISE ID
83704-9251
US

V. Phone/Fax

Practice location:
  • Phone: 541-548-2164
  • Fax: 541-598-3494
Mailing address:
  • Phone: 208-514-2500
  • Fax: 208-375-2217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMRM-2257
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: