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
State | License ID | Taxonomies |
---|---|---|
ID | PA-309 | 363AM0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
1041907 | Other | PACIFIC SOURCE | |
ID | 8059104-00 | Medicaid | |
ID | PA-309 | Other | ID STATE LISC |
ID | PA-309 | Other | ID STATE LISC |
ID | 1667082 | Medicare ID - Type Unspecified |