Provider Demographics
NPI:1699969436
Name:MILLER, GREGG MATHEW (LMT AT)
Entity type:Individual
Prefix:MR
First Name:GREGG
Middle Name:MATHEW
Last Name:MILLER
Suffix:
Gender:M
Credentials:LMT AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5461 E MAYFLOWER LN STE 5
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7892
Mailing Address - Country:US
Mailing Address - Phone:907-376-5757
Mailing Address - Fax:
Practice Address - Street 1:5461 E MAYFLOWER LN STE 5
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7892
Practice Address - Country:US
Practice Address - Phone:907-376-5757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK225400000X, 2255A2300X, 226300000X
AK1220225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist