Healthcare Provider Details

I. General information

NPI: 1497123871
Provider Name (Legal Business Name): CANDACE MILLER MS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2015
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1751 CALLE MEDICO STE O
SANTA FE NM
87505-4706
US

IV. Provider business mailing address

7 AVENIDA VISTA GRANDE # B7-302
SANTA FE NM
87508-9198
US

V. Phone/Fax

Practice location:
  • Phone: 505-391-4242
  • Fax: 505-439-7052
Mailing address:
  • Phone: 505-391-4242
  • Fax: 505-439-7052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License NumberPA-2015-0062
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2015-0062
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2015-0062
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: