Provider Demographics
NPI:1225399504
Name:MILLER, GWEN E (PA-C)
Entity Type:Individual
Prefix:MS
First Name:GWEN
Middle Name:E
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 1:1837 FAIR AVE
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-2121
Mailing Address - Country:US
Mailing Address - Phone:570-253-5838
Mailing Address - Fax:570-253-6678
Practice Address - Street 1:1837 FAIR AVE
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-2121
Practice Address - Country:US
Practice Address - Phone:570-253-5838
Practice Address - Fax:570-253-6678
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001353L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant