Provider Demographics
NPI:1861483455
Name:MILLER, BRIAN DAVID (PA-C BS)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:DAVID
Last Name:MILLER
Suffix:
Gender:M
Credentials:PA-C BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2680 CHANNING WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7517
Mailing Address - Country:US
Mailing Address - Phone:208-523-7667
Mailing Address - Fax:
Practice Address - Street 1:2680 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7517
Practice Address - Country:US
Practice Address - Phone:208-523-7667
Practice Address - Fax:208-523-7668
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-309363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1041907OtherPACIFIC SOURCE
ID8059104-00Medicaid
IDPA-309OtherID STATE LISC
IDPA-309OtherID STATE LISC
ID1667082Medicare ID - Type Unspecified