Provider Demographics
NPI:1942419049
Name:MILLER, DAVID R (PA-C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:MILLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5546
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5546
Mailing Address - Country:US
Mailing Address - Phone:801-475-3500
Mailing Address - Fax:801-475-3489
Practice Address - Street 1:5740 CRESTWOOD DR
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4869
Practice Address - Country:US
Practice Address - Phone:801-479-7771
Practice Address - Fax:801-479-7795
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT107432-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1942419049Medicaid