Provider Demographics
NPI:1083699854
Name:MILLET, KEVIN JON (CRNA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JON
Last Name:MILLET
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 1:210 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3807
Mailing Address - Country:US
Mailing Address - Phone:714-347-1010
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:9674 ARCHIBALD AVE STE 125
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7944
Practice Address - Country:US
Practice Address - Phone:909-296-8930
Practice Address - Fax:909-296-8935
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN543799367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN5437990Medicaid
CARN5437990Medicaid
CABM519XMedicare PIN
CAP01821891 (RESTFUL)Medicare PIN
P76629Medicare UPIN