Provider Demographics
NPI:1093371759
Name:MILLER, EBONY (PA-C)
Entity Type:Individual
Prefix:MS
First Name:EBONY
Middle Name:
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 1:101 E REDLANDS BLVD STE 284
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4721
Mailing Address - Country:US
Mailing Address - Phone:909-312-7380
Mailing Address - Fax:
Practice Address - Street 1:9041 MAGNOLIA AVE STE 206
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3956
Practice Address - Country:US
Practice Address - Phone:951-354-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56608363A00000X
IN10002711A363A00000X, 363AM0700X
TXPA15641363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA56608OtherCALIFORNIA LICENSE
IN10002711AOtherINDIANA LICENSE NUMBER
TXPA15641OtherTEXAS LICENSE