Provider Demographics
NPI:1104562404
Name:W MILYANI MD PLLC
Entity type:Organization
Organization Name:W MILYANI MD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:928-963-9333
Mailing Address - Street 1:9101 W SAHARA AVE # 105-1
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-5772
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1951 MESQUITE AVE STE F
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5746
Practice Address - Country:US
Practice Address - Phone:725-867-7126
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1396847182OtherNPI
1497089874OtherNPI
UT1538896238OtherNPI
1013228394OtherNPI