Provider Demographics
NPI:1043370745
Name:MILLER, JENNIFER SUE (PA - C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUE
Last Name:MILLER
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 1:14302 BARTON BLVD SW
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-5852
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10701 NEW GEORGES CREEK RD SW
Practice Address - Street 2:
Practice Address - City:FROSTBURG
Practice Address - State:MD
Practice Address - Zip Code:21532-1457
Practice Address - Country:US
Practice Address - Phone:301-689-3229
Practice Address - Fax:301-689-1129
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002450L363AM0700X
MDC04108363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAS59781Medicare UPIN
MDP00793395Medicare PIN
MD170267Y1ZMedicare PIN
PA095050TAQMedicare ID - Type Unspecified