Basic Information
| Provider Information | |||||||||
| NPI: | 1639111891 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | LUCIANI | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 NORWICH NEW LONDON TPKE | ||||||||
| Address2: | |||||||||
| City: | UNCASVILLE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063822527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608481297 | ||||||||
| FaxNumber: | 8608489875 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 NORWICH NEW LONDON TPKE | ||||||||
| Address2: | |||||||||
| City: | UNCASVILLE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063822527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608481297 | ||||||||
| FaxNumber: | 8608489875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 11/20/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 1434 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 363A00000X | 001434 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 290001434CT01 | 01 | ANTHEM/ECCG:06-1049086 | OTHER | 625224 | 01 | CONNECTICARE | OTHER | P3617313 | 01 | OXFORD/ECCD: 06-1616101 | OTHER | P3495612 | 01 | OXFORD/ECCG: 06-1049086 | OTHER | 2V5291 | 01 | HEALTHNET/ECCD:06-1616101 | OTHER | 2V5290 | 01 | HEALTHNET/ECCG:06-1049086 | OTHER |