Healthcare Provider Details

I. General information

NPI: 1245227065
Provider Name (Legal Business Name): GARY A MILLER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL CENTER DR
PADUCAH KY
42003-7909
US

IV. Provider business mailing address

140 ROSEMONT DR
PADUCAH KY
42001-9276
US

V. Phone/Fax

Practice location:
  • Phone: 270-442-1024
  • Fax:
Mailing address:
  • Phone: 573-686-5550
  • Fax: 573-686-2136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1029996
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: