Healthcare Provider Details

I. General information

NPI: 1770699407
Provider Name (Legal Business Name): DAVID L MILLER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 MENAUL BLVD NE
ALBUQUERQUE NM
87110-3636
US

IV. Provider business mailing address

PO BOX 130
SAN FIDEL NM
87049-0130
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-5300
  • Fax: 505-552-5490
Mailing address:
  • Phone: 505-552-5300
  • Fax: 505-552-5490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA03057
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberPA03057
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.200433
License Number StateLA
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2015-0004
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: