Provider Demographics
NPI:1417182460
Name:MILLER, JASON ALLEN (IDMT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ALLEN
Last Name:MILLER
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 SIJAN AVE
Mailing Address - Street 2:
Mailing Address - City:WAFB
Mailing Address - State:MO
Mailing Address - Zip Code:65305
Mailing Address - Country:US
Mailing Address - Phone:660-687-2156
Mailing Address - Fax:
Practice Address - Street 1:331 SIJEN AVE
Practice Address - Street 2:
Practice Address - City:WHITEMAN AIR FORCE BASE
Practice Address - State:MO
Practice Address - Zip Code:65305-1269
Practice Address - Country:US
Practice Address - Phone:660-687-2156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-20
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians