Provider Demographics
NPI:1366468365
Name:MILLER, AMY JOSEPHINE (PA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JOSEPHINE
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4005 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-8058
Practice Address - Country:US
Practice Address - Phone:910-848-5437
Practice Address - Fax:910-848-5439
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09647363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291874900Medicaid
FLPA 9102748OtherFLORIDA PHYSICIAN ASSISTANT LICENSE