Provider Demographics
NPI:1982189536
Name:MILLER, TROY JAMES
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:JAMES
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:HARRIET
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3801 OAK PARK CIR SE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55904-6188
Mailing Address - Country:US
Mailing Address - Phone:507-206-3548
Mailing Address - Fax:
Practice Address - Street 1:3801 OAK PARK CIR SE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-6188
Practice Address - Country:US
Practice Address - Phone:507-206-3548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-29
Last Update Date:2018-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1044749-6-AFC253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1044749-6-AFCMedicaid