Provider Demographics
NPI:1629039995
Name:MILLER, WAYNE ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:ROBERT
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:SHAMOKIN
Mailing Address - State:PA
Mailing Address - Zip Code:17872-5811
Mailing Address - Country:US
Mailing Address - Phone:570-644-5050
Mailing Address - Fax:570-644-2798
Practice Address - Street 1:255 W SPRUCE ST
Practice Address - Street 2:
Practice Address - City:SHAMOKIN
Practice Address - State:PA
Practice Address - Zip Code:17872-5811
Practice Address - Country:US
Practice Address - Phone:570-644-5050
Practice Address - Fax:570-644-2798
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042431L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001206879Medicaid
PA393857Medicare PIN