Individual
RILEE WONG MICKELSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
1072 N LIBERTY ST STE 201, BOISE, ID 83704-8708
(208) 302-2400
(208) 302-2455
Mailing address
PO BOX 190930, BOISE, ID 83719-0930
(208) 367-5170
(208) 367-5180
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
MA065365
PA
363AS0400X
Surgical Physician Assistant
Primary
8061671
ID
363AS0400X
Surgical Physician Assistant
MA065365
PA
Other
Enumeration date
02/01/2024
Last updated
09/03/2024
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