Provider Demographics
NPI:1194156711
Name:MILLER, CARL
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 OAK LN
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:NY
Mailing Address - Zip Code:12170-2210
Mailing Address - Country:US
Mailing Address - Phone:518-796-2096
Mailing Address - Fax:
Practice Address - Street 1:4 OAK LN
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:NY
Practice Address - Zip Code:12170-2210
Practice Address - Country:US
Practice Address - Phone:518-796-2096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-07
Last Update Date:2013-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY287378164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse