Provider Demographics
NPI:1336546209
Name:MILLER, ETTHAN CHARLES
Entity Type:Individual
Prefix:MR
First Name:ETTHAN
Middle Name:CHARLES
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 1:1785 W LEE HWY
Mailing Address - Street 2:P.O. BOX 662
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-1437
Mailing Address - Country:US
Mailing Address - Phone:276-228-6499
Mailing Address - Fax:276-228-6165
Practice Address - Street 1:1785 W LEE HWY
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1437
Practice Address - Country:US
Practice Address - Phone:276-620-4246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001111520163WE0003X, 163WX0106X
VA0024172389363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No163WX0106XNursing Service ProvidersRegistered NurseOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1336546209Medicaid
VA1336546209Medicaid