Provider Demographics
NPI:1972023885
Name:MILLER, JESSE (DO)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 S CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-4141
Mailing Address - Country:US
Mailing Address - Phone:307-200-9669
Mailing Address - Fax:
Practice Address - Street 1:1233 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2988
Practice Address - Country:US
Practice Address - Phone:307-577-7201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WY12323A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program