Basic Information
Provider Information
NPI: 1003141680
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MILES
FirstName: SANDRA
MiddleName: R
NamePrefix:  
NameSuffix:  
Credential: CRNA, RN, BSN
OtherOrganizationName:  
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Mailing Information
Address1: 713 W VIRGINIA AVE
Address2:  
City: DUNBAR
State: WV
PostalCode: 250643219
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 501 MORRIS ST
Address2:  
City: CHARLESTON
State: WV
PostalCode: 253011326
CountryCode: US
TelephoneNumber: 3043885432
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/15/2009
LastUpdateDate: 10/15/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
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IsSoleProprietor: Y
IsOrganizationSubpart:  
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AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
367500000X50874WVY Physician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered 

No ID Information.


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