Provider Demographics
NPI:1891787958
Name:MILLER, MARY S (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:MILLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 PRAIRIE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-1627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8990 SPRINGBROOK DR NW
Practice Address - Street 2:STE 250
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5850
Practice Address - Country:US
Practice Address - Phone:763-398-0099
Practice Address - Fax:763-398-0124
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 065750-5367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN39G23MIOtherBCBSMN
MN087343800Medicaid
MN430003279Medicare PIN