Basic Information
| Provider Information | |||||||||
| NPI: | 1730277021 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | FRANK | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1221 SW CREEKSIDE DR | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640813254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163470088 | ||||||||
| FaxNumber: | 8163470088 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 HOLMES ST | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641082640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164041100 | ||||||||
| FaxNumber: | 8164041103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 133958 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 913766002 | 05 | MO | MEDICAID |