Provider Demographics
NPI:1275868572
Name:MILLER, KENNETH DOMINIQUE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:DOMINIQUE
Last Name:MILLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 GAGE BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-942-2268
Practice Address - Street 1:875 SWIFT BLVD
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3592
Practice Address - Country:US
Practice Address - Phone:509-946-1654
Practice Address - Fax:509-943-5652
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60115570363AM0700X, 363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2004006Medicaid
WA0255435OtherLIWA VCR
WA0016MIOtherBSWA KADLEC
OR500619959Medicaid
ID808497500Medicaid
WAP00781687OtherRRGA
WAG8885960Medicare PIN