Provider Demographics
NPI:1649838186
Name:MILLER, JOHNATHAN DOUGLAS
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:DOUGLAS
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:PO BOX 852
Mailing Address - Street 2:
Mailing Address - City:TOK
Mailing Address - State:AK
Mailing Address - Zip Code:99780-0852
Mailing Address - Country:US
Mailing Address - Phone:907-324-2136
Mailing Address - Fax:
Practice Address - Street 1:TETLIN CLINIC
Practice Address - Street 2:
Practice Address - City:TETLIN
Practice Address - State:AK
Practice Address - Zip Code:99779
Practice Address - Country:US
Practice Address - Phone:907-324-2136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker