Provider Demographics
NPI:1700866852
Name:MILLER, TIMOTHY (NP)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17431 N 71ST DR
Mailing Address - Street 2:STE 103
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8598
Mailing Address - Country:US
Mailing Address - Phone:480-521-6586
Mailing Address - Fax:623-242-7856
Practice Address - Street 1:17431 N 71ST DR
Practice Address - Street 2:STE 103
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8598
Practice Address - Country:US
Practice Address - Phone:480-521-6586
Practice Address - Fax:623-242-7856
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3087363LP0808X
AZAP2246363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ96322OtherAHCCCS NUMBER