Basic Information
| Provider Information | |||||||||
| NPI: | 1942485719 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | GAYLE | ||||||||
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| Credential: | FAM NURSE PRACTIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 CARSON AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LA JUNTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810502751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193835900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1100 CARSON AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LA JUNTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810502751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193835900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2007 | ||||||||
| LastUpdateDate: | 07/07/2011 | ||||||||
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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 | 363LF0000X | NP-5129 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 74637801 | 05 | CO | MEDICAID |