Provider Demographics
NPI:1255316998
Name:MILLER, LARRY (CRNA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
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 1:5253 DIJON DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4312
Mailing Address - Country:US
Mailing Address - Phone:225-768-1611
Mailing Address - Fax:225-768-1615
Practice Address - Street 1:5253 DIJON DR
Practice Address - Street 2:SUITE A
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4312
Practice Address - Country:US
Practice Address - Phone:225-768-1611
Practice Address - Fax:225-768-1615
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP02275367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1397326Medicaid
LA56302Medicare ID - Type Unspecified