Provider Demographics
NPI:1699060962
Name:MILLER, BRYAN THOMAS (RN, BSN)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:THOMAS
Last Name:MILLER
Suffix:
Gender:M
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9224 170TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MN
Mailing Address - Zip Code:55025-9419
Mailing Address - Country:US
Mailing Address - Phone:651-788-5996
Mailing Address - Fax:
Practice Address - Street 1:9224 170TH AVE NE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MN
Practice Address - Zip Code:55025-9419
Practice Address - Country:US
Practice Address - Phone:651-788-5996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-202035-0163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse