Provider Demographics
NPI:1053304691
Name:MILLER, TAMMY MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:MARIE
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:MARIE
Other - Last Name:DOUGHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPAS, RPA-C
Mailing Address - Street 1:PO BOX 858
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0858
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:30 HOPE DR
Practice Address - Street 2:BUILDING B, SUITE 2400
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2036
Practice Address - Country:US
Practice Address - Phone:717-531-5638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010673-1363A00000X
PAMA054733363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1032833230001Medicaid