Provider Demographics
NPI:1295236123
Name:MILLER, WENDELL DAVE
Entity type:Individual
Prefix:
First Name:WENDELL
Middle Name:DAVE
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 PETER CT
Mailing Address - Street 2:
Mailing Address - City:SOUTH HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11746-4501
Mailing Address - Country:US
Mailing Address - Phone:631-748-7730
Mailing Address - Fax:
Practice Address - Street 1:3 PETER CT
Practice Address - Street 2:
Practice Address - City:SOUTH HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11746-4501
Practice Address - Country:US
Practice Address - Phone:631-748-7730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007714225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$OtherSOCIAL SECUTITY NUMBER
NY$$$$$$$$$OtherSOCIAL SECURITY NUMBER