Healthcare Provider Details

I. General information

NPI: 1871946160
Provider Name (Legal Business Name): BRENT JORDAN MILLER APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2016
Last Update Date: 07/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9400 EAST 350 HIGHWAY
RAYTOWN MO
64133
US

IV. Provider business mailing address

8312 HEDGES AVE
RAYTOWN MO
64138-3440
US

V. Phone/Fax

Practice location:
  • Phone: 816-251-5700
  • Fax:
Mailing address:
  • Phone: 816-316-9835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2016019762
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-77307-021
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: