Healthcare Provider Details

I. General information

NPI: 1841977733
Provider Name (Legal Business Name): BENJAMIN MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2023
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18068 VIA ROMA
YORBA LINDA CA
92886-2872
US

IV. Provider business mailing address

18068 VIA ROMA
YORBA LINDA CA
92886-2872
US

V. Phone/Fax

Practice location:
  • Phone: 714-651-3980
  • Fax:
Mailing address:
  • Phone: 714-651-3980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA65613
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: