Provider Demographics
NPI:1093111510
Name:MILLER, KERI LONG (PA-C)
Entity Type:Individual
Prefix:
First Name:KERI
Middle Name:LONG
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 1:303 N CLYDE MORRIS BLVD # 10E
Mailing Address - Street 2:PBFS DEPARTMENT
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2709
Mailing Address - Country:US
Mailing Address - Phone:386-226-4590
Mailing Address - Fax:386-425-6197
Practice Address - Street 1:1165 DUNLAWTON AVE STE 105
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-2924
Practice Address - Country:US
Practice Address - Phone:386-425-4787
Practice Address - Fax:386-425-4788
Is Sole Proprietor?:No
Enumeration Date:2014-11-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9108344363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013803400Medicaid