Provider Demographics
NPI:1124413190
Name:MILLAR, ALYSSA (PA-C)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:MILLAR
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 1:553 KINGSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-3600
Mailing Address - Country:US
Mailing Address - Phone:401-304-9111
Mailing Address - Fax:
Practice Address - Street 1:553 KINGSTOWN RD
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-3600
Practice Address - Country:US
Practice Address - Phone:401-304-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00802363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPA00802OtherLICENSE