Basic Information
| Provider Information | |||||||||
| NPI: | 1851545958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | BRUCE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5059 HWY 70 W | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285574503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2528083696 | ||||||||
| FaxNumber: | 2528082022 | ||||||||
| Practice Location | |||||||||
| Address1: | 5059 HWY 70 W | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285574503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2528083696 | ||||||||
| FaxNumber: | 2528082022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2008 | ||||||||
| LastUpdateDate: | 06/23/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 012936 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0010-04644 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 012936 | 01 | NY | LICENSE | OTHER | MM1864265 | 01 | DEA | OTHER |