Individual
MIRANDA MICHELLE VAN DAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CSFA
Contact information
Practice address
500 S. EAGLE RD., MERIDIAN, ID 83642
(208) 706-8101
Mailing address
3595 W SPRUCE CREEK DR, MERIDIAN, ID 83642-4217
(208) 602-7289
Taxonomy
Speciality
Code
Description
License number
State
246ZC0007X
Surgical Assistant
Primary
205983
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
205983
NATIONAL BOARD OF SURGICAL TECHNOLOGY AND SURGICAL ASSISTING
ID
Enumeration date
12/10/2021
Last updated
12/10/2021
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