Provider Demographics
NPI:1316270168
Name:MILLER, IAN DOUGLAS (PA)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:DOUGLAS
Last Name:MILLER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 FOUR STATES DR STE 1
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:KS
Mailing Address - Zip Code:66739-4305
Mailing Address - Country:US
Mailing Address - Phone:620-783-2356
Mailing Address - Fax:620-783-2395
Practice Address - Street 1:198 FOUR STATES DR.
Practice Address - Street 2:SUITE 1
Practice Address - City:GALENA
Practice Address - State:KS
Practice Address - Zip Code:66739-4305
Practice Address - Country:US
Practice Address - Phone:620-783-2356
Practice Address - Fax:620-783-2395
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-11
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009026344363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant