Healthcare Provider Details

I. General information

NPI: 1508783960
Provider Name (Legal Business Name): NICHOLAS ALAN MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

381 WHITE TAIL LANE APT 113
JACKSON MN
56143
US

IV. Provider business mailing address

381 WHITE TAIL LANE APT 113
JACKSON MN
56143
US

V. Phone/Fax

Practice location:
  • Phone: 507-230-4118
  • Fax:
Mailing address:
  • Phone: 507-230-4118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2543153
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: