Provider Demographics
NPI:1770699407
Name:MILLER, DAVID L (PA-C)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:L
Last Name:MILLER
Suffix:
Gender:M
Credentials:PA-C
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 130
Mailing Address - Street 2:
Mailing Address - City:SAN FIDEL
Mailing Address - State:NM
Mailing Address - Zip Code:87049-0130
Mailing Address - Country:US
Mailing Address - Phone:505-552-5300
Mailing Address - Fax:505-552-5490
Practice Address - Street 1:7400 MENAUL BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3636
Practice Address - Country:US
Practice Address - Phone:505-552-5300
Practice Address - Fax:505-552-5490
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03057363AM0700X, 207P00000X
LAPA.200433363AM0700X
NMPA2015-0004363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH3451Medicaid
TXPA03057OtherTEXAS BOARD OF MEDICAL EXAMINERS
NMPA 2015-0004OtherPA LICENSE
LAPA.200433OtherLOUISIANA BOARD OF MEDICAL EXAMINERS
NMH3451Medicaid