Provider Demographics
NPI:1275538738
Name:MCMILLAN, MALCOLM A (CRNA)
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:A
Last Name:MCMILLAN
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 6270
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71136-6270
Mailing Address - Country:US
Mailing Address - Phone:318-683-0411
Mailing Address - Fax:318-603-5461
Practice Address - Street 1:255 BERT KOUNS LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-8150
Practice Address - Country:US
Practice Address - Phone:318-683-0411
Practice Address - Fax:318-603-5461
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN078292367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1428442Medicaid
LASP265Medicare ID - Type Unspecified