Provider Demographics
NPI:1245227065
Name:MILLER, GARY A (CRNA)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:A
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 1:140 ROSEMONT DR
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-9276
Mailing Address - Country:US
Mailing Address - Phone:573-686-5550
Mailing Address - Fax:573-686-2136
Practice Address - Street 1:100 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7909
Practice Address - Country:US
Practice Address - Phone:270-442-1024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1029996367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000318171OtherKY BCBS INDIVIDUAL
KYP00060094OtherRR MEDICARE
KY74353079Medicaid
KY00545001Medicare PIN
KY74353079Medicaid
KY0789401Medicare PIN