Provider Demographics
NPI:1457344723
Name:MILLER, LARRY DOUGLAS (PA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DOUGLAS
Last Name:MILLER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 RUSHTON ST
Mailing Address - Street 2:
Mailing Address - City:GARDENDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35071-3819
Mailing Address - Country:US
Mailing Address - Phone:205-631-1025
Mailing Address - Fax:
Practice Address - Street 1:820 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1111
Practice Address - Country:US
Practice Address - Phone:205-327-5030
Practice Address - Fax:205-327-5616
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA-0115363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant