Healthcare Provider Details

I. General information

NPI: 1447297528
Provider Name (Legal Business Name): GARY LEE MILLER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 N CLYDE MORRIS BLVD
DAYTONA BEACH FL
32114-2781
US

IV. Provider business mailing address

PO BOX 100254
GAINESVILLE FL
32610-0254
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-8610
  • Fax: 352-273-8612
Mailing address:
  • Phone: 352-273-8610
  • Fax: 352-273-8612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number066569
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN1787402
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: