Healthcare Provider Details

I. General information

NPI: 1417952896
Provider Name (Legal Business Name): DOUGLAS E MILLER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WEST AVE S
LA CROSSE WI
54601-8806
US

IV. Provider business mailing address

200 1ST ST SW
ROCHESTER MN
55905-1510
US

V. Phone/Fax

Practice location:
  • Phone: 608-782-9760
  • Fax:
Mailing address:
  • Phone: 608-785-0940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number892
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number892
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001037
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: