Provider Demographics
NPI:1043265101
Name:MILLER, TERRY W (CRNA)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:W
Last Name:MILLER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-3810
Mailing Address - Country:US
Mailing Address - Phone:417-347-1078
Mailing Address - Fax:417-347-1079
Practice Address - Street 1:1102 W 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804
Practice Address - Country:US
Practice Address - Phone:417-347-1078
Practice Address - Fax:417-347-1079
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006001065367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00309835OtherRR MEDICARE
KS200369410AMedicaid
MO910527308Medicaid
OK200075970AMedicaid
KS200369410AMedicaid
MO829460096Medicare PIN