Basic Information
Provider Information | |||||||||
NPI: | 1275868572 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILLER | ||||||||
FirstName: | KENNETH | ||||||||
MiddleName: | DOMINIQUE | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 560 GAGE BLVD | ||||||||
Address2: | SUITE 203 | ||||||||
City: | RICHLAND | ||||||||
State: | WA | ||||||||
PostalCode: | 99352 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5099423627 | ||||||||
FaxNumber: | 5099422268 | ||||||||
Practice Location | |||||||||
Address1: | 875 SWIFT BLVD | ||||||||
Address2: |   | ||||||||
City: | RICHLAND | ||||||||
State: | WA | ||||||||
PostalCode: | 993523592 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5099461654 | ||||||||
FaxNumber: | 5099435652 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/05/2009 | ||||||||
LastUpdateDate: | 01/23/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA60115570 | WA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA60115570 | WA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AS0400X | PA60115570 | WA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | 2004006 | 05 | WA |   | MEDICAID | 0255435 | 01 | WA | LIWA VCR | OTHER | 0016MI | 01 | WA | BSWA KADLEC | OTHER | 500619959 | 05 | OR |   | MEDICAID | 808497500 | 05 | ID |   | MEDICAID | P00781687 | 01 | WA | RRGA | OTHER |