Provider Demographics
NPI:1306198205
Name:MILLER, JOHN BLAKE
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BLAKE
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98-838 NOELANI ST
Mailing Address - Street 2:APT. 101
Mailing Address - City:PEARL CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96782-3501
Mailing Address - Country:US
Mailing Address - Phone:224-628-1002
Mailing Address - Fax:
Practice Address - Street 1:98-838 NOELANI ST
Practice Address - Street 2:APT. 101
Practice Address - City:PEARL CITY
Practice Address - State:HI
Practice Address - Zip Code:96782-3501
Practice Address - Country:US
Practice Address - Phone:224-628-1002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207PE0005X146M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate