Provider Demographics
NPI:1417987330
Name:MILLER, MARK ALLEN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLEN
Last Name:MILLER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:800 ROSE ST
Mailing Address - Street 2:DEPARTMENT OF ANESTHESIA N202
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0001
Mailing Address - Country:US
Mailing Address - Phone:859-323-5956
Mailing Address - Fax:859-323-1080
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:DEPARTMENT OF ANESTHESIA N202
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-3008
Practice Address - Country:US
Practice Address - Phone:859-323-5956
Practice Address - Fax:859-323-1080
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4740A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0943036Medicare ID - Type Unspecified