Healthcare Provider Details

I. General information

NPI: 1396883476
Provider Name (Legal Business Name): GREGORY DON MILLER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 US HIGHWAY 431
BOAZ AL
35957
US

IV. Provider business mailing address

1535 NORTHRIDGE TRCE
ALBERTVILLE AL
35951-4266
US

V. Phone/Fax

Practice location:
  • Phone: 256-593-8310
  • Fax:
Mailing address:
  • Phone: 256-891-1083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-052526
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: