Healthcare Provider Details

I. General information

NPI: 1336546209
Provider Name (Legal Business Name): MR. ETTHAN CHARLES MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2014
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 VIRGINIA AVE STE A
WYTHEVILLE VA
24382-1185
US

IV. Provider business mailing address

360 VIRGINIA AVE STE A
WYTHEVILLE VA
24382-1185
US

V. Phone/Fax

Practice location:
  • Phone: 276-620-4246
  • Fax:
Mailing address:
  • Phone: 276-335-2038
  • Fax: 276-625-8865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number0001111520
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License Number0001111520
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024172389
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: