Provider Demographics
NPI:1093023319
Name:MILLER, AUTUMN R (PA-C)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:R
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:R
Other - Last Name:POST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2601 FIELDCREST DR
Mailing Address - Street 2:
Mailing Address - City:KAUKAUNA
Mailing Address - State:WI
Mailing Address - Zip Code:54130-4523
Mailing Address - Country:US
Mailing Address - Phone:920-462-6100
Mailing Address - Fax:920-462-6107
Practice Address - Street 1:2601 FIELDCREST DR
Practice Address - Street 2:
Practice Address - City:KAUKAUNA
Practice Address - State:WI
Practice Address - Zip Code:54130-4523
Practice Address - Country:US
Practice Address - Phone:920-462-6100
Practice Address - Fax:920-462-6107
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2661-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1093851OtherNCCPA CERTIFICATION
WI2661-023OtherWI LICENSE
WI078450056Medicare Oscar/Certification
1093851OtherNCCPA CERTIFICATION
WI071700061Medicare Oscar/Certification