Provider Demographics
NPI:1134201197
Name:MILLER, RICHARD (PA-C)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4559 MOOSE CREEK AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-6921
Mailing Address - Country:US
Mailing Address - Phone:907-488-1692
Mailing Address - Fax:
Practice Address - Street 1:39 N BIRCH ST
Practice Address - Street 2:
Practice Address - City:LANSE
Practice Address - State:MI
Practice Address - Zip Code:49946-1548
Practice Address - Country:US
Practice Address - Phone:906-525-2667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAK 434363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical