Healthcare Provider Details

I. General information

NPI: 1598896953
Provider Name (Legal Business Name): JOHN BRENT MILES PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 02/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6555 COYLE AVENUE
CARMICHAEL CA
95608
US

IV. Provider business mailing address

3400 DATA DR PHYSICIAN SUPPORT SERVICES
RANCHO CORDOVA CA
95670-7956
US

V. Phone/Fax

Practice location:
  • Phone: 916-536-3670
  • Fax: 916-536-2480
Mailing address:
  • Phone: 916-379-2948
  • Fax: 916-858-7065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA05080
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA05080
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA22162
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA22162
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: