Provider Demographics
NPI:1265864359
Name:JACOBSEN MILLER, BRET LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:BRET
Middle Name:LEE
Last Name:JACOBSEN MILLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3637 W ECHO LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-4753
Mailing Address - Country:US
Mailing Address - Phone:602-317-6644
Mailing Address - Fax:
Practice Address - Street 1:11034 N 23RD DR STE 105B
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4743
Practice Address - Country:US
Practice Address - Phone:602-639-0189
Practice Address - Fax:844-955-2502
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ5445363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant