Provider Demographics
NPI:1306845243
Name:MILLER, JUDITH L (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:L
Last Name:MILLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:4695 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:SPRING PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55384-9715
Mailing Address - Country:US
Mailing Address - Phone:952-442-7890
Mailing Address - Fax:952-442-7893
Practice Address - Street 1:4695 SHORELINE DR
Practice Address - Street 2:
Practice Address - City:SPRING PARK
Practice Address - State:MN
Practice Address - Zip Code:55384-9715
Practice Address - Country:US
Practice Address - Phone:952-442-7890
Practice Address - Fax:952-442-7893
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0732886363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN412726900Medicaid
MNR0732886OtherRN LICENSE
MNP68941Medicare UPIN