Provider Demographics
NPI:1609928191
Name:MILLER, KENNETH DEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DEAN
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 1:3349 G ST STE F
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-0978
Mailing Address - Country:US
Mailing Address - Phone:209-349-8459
Mailing Address - Fax:209-349-8650
Practice Address - Street 1:3349 G ST STE F
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340
Practice Address - Country:US
Practice Address - Phone:209-349-8459
Practice Address - Fax:209-349-8650
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10104363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP43503Medicare UPIN
CAGC089ZMedicare PIN
CAGC089YMedicare PIN