Healthcare Provider Details

I. General information

NPI: 1366892598
Provider Name (Legal Business Name): PETER MICHAEL MILLARD CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2016
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 S CENTRAL AVE
MEDFORD OR
97501-7822
US

IV. Provider business mailing address

931 CHEVY WAY
MEDFORD OR
97504-4127
US

V. Phone/Fax

Practice location:
  • Phone: 541-618-1380
  • Fax: 541-618-1385
Mailing address:
  • Phone: 541-690-3555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201903896NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: