Provider Demographics
NPI:1801377114
Name:MILLER, KERRY RYAN
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:RYAN
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 1:109 FM 126
Mailing Address - Street 2:
Mailing Address - City:MERKEL
Mailing Address - State:TX
Mailing Address - Zip Code:79536
Mailing Address - Country:US
Mailing Address - Phone:325-370-5909
Mailing Address - Fax:
Practice Address - Street 1:109 FM 126
Practice Address - Street 2:
Practice Address - City:MERKEL
Practice Address - State:TX
Practice Address - Zip Code:79536-7953
Practice Address - Country:US
Practice Address - Phone:325-370-5909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2122370225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX676416OtherMCR
TX001028687Medicaid