Provider Demographics
NPI:1902899073
Name:MILLER, DOUGLAS DEAN (MSN, FNP)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:DEAN
Last Name:MILLER
Suffix:
Gender:M
Credentials:MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 ELM AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKY FORD
Mailing Address - State:CO
Mailing Address - Zip Code:81067-1328
Mailing Address - Country:US
Mailing Address - Phone:719-254-7421
Mailing Address - Fax:719-254-6966
Practice Address - Street 1:1014 ELM AVE
Practice Address - Street 2:
Practice Address - City:ROCKY FORD
Practice Address - State:CO
Practice Address - Zip Code:81067-1328
Practice Address - Country:US
Practice Address - Phone:719-254-7421
Practice Address - Fax:719-254-6966
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2020-06-04
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-12
Provider Licenses
StateLicense IDTaxonomies
CO106502, RXN, NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO70077371Medicaid
CO70077371Medicaid