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General NPI Number Information
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NPI Number | 1104562404
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Entity Type | Organization
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Legal Business Name | W MILYANI MD PLLC
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Dates
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Enumeration Date | 05/09/2022
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Last Update Date | 01/09/2023
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Provider Practice Location Address
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Address Line | 1951 MESQUITE AVE STE F
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5746
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Country | US
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Telephone | 725-867-7126
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Fax |
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Provider Business Mailing Address
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Address Line | 9101 W SAHARA AVE # 105-1
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City | LAS VEGAS
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State | NV
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Zip | 89117-5772
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | CLINTON MARTIN
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Credential | PA-C
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Telephone | 928-963-9333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number |
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License Number State |
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