Healthcare Provider Details

I. General information

NPI: 1720373400
Provider Name (Legal Business Name): PAUL ANDREW MISKA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2011
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

PO BOX 3870
SALT LAKE CITY UT
84110-3870
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-3578
  • Fax: 801-662-3583
Mailing address:
  • Phone: 801-662-3578
  • Fax: 801-662-3583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberR-9232
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number64180
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberDO176139
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number64180
License Number StateWI
# 5
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number11234377-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: