Provider Demographics
NPI:1598186348
Name:MILLER, MARVIN RAY (CRNA)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:RAY
Last Name:MILLER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13213 S SEGO RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:67514-9422
Mailing Address - Country:US
Mailing Address - Phone:620-727-3926
Mailing Address - Fax:
Practice Address - Street 1:13410 W LAKE CABLE RD
Practice Address - Street 2:
Practice Address - City:PARTRIDGE
Practice Address - State:KS
Practice Address - Zip Code:67566-9026
Practice Address - Country:US
Practice Address - Phone:620-727-3926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-20
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS43-557214-072367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS43-557214-072OtherKANSAS STATE BOARD OF NURSING