Provider Demographics
NPI:1710525191
Name:MILLER, WENDELL JOSEPH
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:JOSEPH
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:483 LAUREL LN APT 210
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-6185
Mailing Address - Country:US
Mailing Address - Phone:719-551-7837
Mailing Address - Fax:
Practice Address - Street 1:483 LAUREL LN APT 210
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-6185
Practice Address - Country:US
Practice Address - Phone:719-551-7837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX43553189172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver