Provider Demographics
NPI:1336201136
Name:MILLER, CAROL W
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:W
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 E 30TH ST BLDG D
Mailing Address - Street 2:STE 101
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8990
Mailing Address - Country:US
Mailing Address - Phone:505-327-1400
Mailing Address - Fax:505-566-3202
Practice Address - Street 1:2300 E 30TH ST BLDG D
Practice Address - Street 2:STE 101
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8990
Practice Address - Country:US
Practice Address - Phone:505-327-1400
Practice Address - Fax:505-566-3202
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2004-0032363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM52889718Medicaid
NMNM300639Medicare PIN