Provider Demographics
NPI:1609854454
Name:MILLER, BRIAN L (CRNA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:L
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 1:51 OLD RIVER RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865
Mailing Address - Country:US
Mailing Address - Phone:401-480-6864
Mailing Address - Fax:401-475-0266
Practice Address - Street 1:115 CASS AVE
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-4705
Practice Address - Country:US
Practice Address - Phone:401-769-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN242566367500000X
RIRNA36599367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110124896AMedicaid