Provider Demographics
NPI:1053625426
Name:MILLER, KENDAL W (CRNA)
Entity type:Individual
Prefix:
First Name:KENDAL
Middle Name:W
Last Name:MILLER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 ARNOLD DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK AFB
Mailing Address - State:AR
Mailing Address - Zip Code:72099-4933
Mailing Address - Country:US
Mailing Address - Phone:501-987-7445
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-9588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06178367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2125630Medicaid
LA1053625426OtherBCBS OF LA
LA1053625426OtherBCBS OF LA