Provider Demographics
NPI:1730184052
Name:MIILLER, VANESSA L (PA-C)
Entity type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:L
Last Name:MIILLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 295
Mailing Address - Street 2:
Mailing Address - City:CORSICA
Mailing Address - State:SD
Mailing Address - Zip Code:57328-0295
Mailing Address - Country:US
Mailing Address - Phone:605-946-5775
Mailing Address - Fax:
Practice Address - Street 1:708 8TH ST
Practice Address - Street 2:
Practice Address - City:ARMOUR
Practice Address - State:SD
Practice Address - Zip Code:57313-2102
Practice Address - Country:US
Practice Address - Phone:605-724-2151
Practice Address - Fax:605-724-2310
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0214363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD21229OtherSIOUX VALLEY HEALTH PLAN
SD4999898OtherBLUE CROSS
SD6820243Medicaid
SD6820243Medicaid