Healthcare Provider Details

I. General information

NPI: 1053625426
Provider Name (Legal Business Name): KENDAL W MILLER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2010
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234-4504
US

IV. Provider business mailing address

1090 ARNOLD DR
LITTLE ROCK AFB AR
72099-4933
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-9588
  • Fax:
Mailing address:
  • Phone: 501-987-7445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP06178
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: