Provider Demographics
NPI:1518401397
Name:MILLER, RAYMOND M (NP-C)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:M
Last Name:MILLER
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5546
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5546
Mailing Address - Country:US
Mailing Address - Phone:801-475-3500
Mailing Address - Fax:801-475-3161
Practice Address - Street 1:4700 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4303
Practice Address - Country:US
Practice Address - Phone:801-475-3160
Practice Address - Fax:801-475-3161
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7685189-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1518401397Medicaid