Provider Demographics
NPI:1497380430
Name:MILLER, COREY
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
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 1:30 BROOK DR
Mailing Address - Street 2:
Mailing Address - City:UNION HALL
Mailing Address - State:VA
Mailing Address - Zip Code:24176-2319
Mailing Address - Country:US
Mailing Address - Phone:304-654-6799
Mailing Address - Fax:
Practice Address - Street 1:1900 ELECTRIC RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7474
Practice Address - Country:US
Practice Address - Phone:540-776-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001270816163W00000X
VA0024179401367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse