Provider Demographics
NPI:1720319528
Name:MILLER, CARROLL KEATLEY II (CRNA)
Entity Type:Individual
Prefix:MR
First Name:CARROLL
Middle Name:KEATLEY
Last Name:MILLER
Suffix:II
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 WESTWOOD AVE UNIT 208
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-4631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 BROAD ROCK BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23224-4915
Practice Address - Country:US
Practice Address - Phone:804-675-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-19
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9308821163W00000X
VA0001227192163W00000X
VA0024169026367500000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse