Provider Demographics
NPI:1902864648
Name:MILLER, MARK LEE (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:LEE
Last Name:MILLER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 PREMIER DR
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6076
Mailing Address - Country:US
Mailing Address - Phone:507-386-6600
Mailing Address - Fax:507-625-5971
Practice Address - Street 1:1431 PREMIER DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6076
Practice Address - Country:US
Practice Address - Phone:507-386-6650
Practice Address - Fax:507-345-4416
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1298225100000X
MN10142255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA025OtherTRICARE
MNHP34312OtherHEALTH PARTNERS
MN126934E354OtherUCARE
MN33441MIOtherBCBS OF MN
MN6400235OtherMEDICA, FARIBAULT
MN983181027668OtherPREFERRED ONE
MN6400223OtherMEDICA, MANKATO