Provider Demographics
NPI:1518919257
Name:MILLER, REGAN RUSS (PA-C)
Entity Type:Individual
Prefix:
First Name:REGAN
Middle Name:RUSS
Last Name:MILLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 W LINCOLN ST
Mailing Address - Street 2:STE 100
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1902
Mailing Address - Country:US
Mailing Address - Phone:618-222-3200
Mailing Address - Fax:618-222-3203
Practice Address - Street 1:311 W LINCOLN ST
Practice Address - Street 2:STE 100
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1902
Practice Address - Country:US
Practice Address - Phone:618-222-3200
Practice Address - Fax:618-222-3203
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO1070753363AM0700X
IL085.005034363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical