Healthcare Provider Details

I. General information

NPI: 1083751903
Provider Name (Legal Business Name): BRIAN L MILLER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 10/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 S MAIN ST
VIROQUA WI
54665-2059
US

IV. Provider business mailing address

507 S MAIN ST
VIROQUA WI
54665-2059
US

V. Phone/Fax

Practice location:
  • Phone: 608-637-4230
  • Fax: 608-637-4214
Mailing address:
  • Phone: 608-637-2101
  • Fax: 608-638-5042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number121273030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: