Healthcare Provider Details

I. General information

NPI: 1124972526
Provider Name (Legal Business Name): HOMER ANDREW MILLER IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2026
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 N PERIMETER RD
MALMSTROM AFB MT
59402-6701
US

IV. Provider business mailing address

4656 W MILES RD
JANESVILLE WI
53545-9079
US

V. Phone/Fax

Practice location:
  • Phone: 406-731-4389
  • Fax:
Mailing address:
  • Phone: 406-731-4389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License NumberL5ALJ4N051C00AB
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: