Provider Demographics
NPI:1740249515
Name:MILLER, TERRY WAYNE (NP)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:WAYNE
Last Name:MILLER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-9413
Mailing Address - Country:US
Mailing Address - Phone:662-377-4652
Mailing Address - Fax:662-377-4656
Practice Address - Street 1:903 MISSISSIPPI DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-0928
Practice Address - Country:US
Practice Address - Phone:662-377-4652
Practice Address - Fax:662-377-4656
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR850611363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120504Medicaid
MS500000520Medicare PIN
MSS83813Medicare UPIN