Healthcare Provider Details

I. General information

NPI: 1851319438
Provider Name (Legal Business Name): GARY ALAN MILLER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1361 WENNER RD
DETROIT LAKES MN
56501-7918
US

IV. Provider business mailing address

1702 UNIVERSITY DR S
FARGO ND
58103-4940
US

V. Phone/Fax

Practice location:
  • Phone: 218-846-9981
  • Fax: 218-846-9983
Mailing address:
  • Phone: 701-364-4222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAC0115
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9365
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: