Healthcare Provider Details

I. General information

NPI: 1154681187
Provider Name (Legal Business Name): JASON RONALD MILLER LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11309 NE 359TH ST
LA CENTER WA
98629-3643
US

IV. Provider business mailing address

11309 NE 359TH ST
LA CENTER WA
98629-3643
US

V. Phone/Fax

Practice location:
  • Phone: 360-907-2782
  • Fax: 360-263-6544
Mailing address:
  • Phone: 360-907-2782
  • Fax: 360-263-6544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP60272616
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: