Provider Demographics
NPI:1376519876
Name:MILLER, ELEANOR S (PA)
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:S
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 1:2500 NESCONSET HWY BLDG 16
Mailing Address - Street 2:SUITE 63C
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2555
Mailing Address - Country:US
Mailing Address - Phone:631-444-6250
Mailing Address - Fax:631-444-6665
Practice Address - Street 1:2500 NESCONSET HWY BLDG 16
Practice Address - Street 2:SUITE 63C
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2555
Practice Address - Country:US
Practice Address - Phone:631-444-6250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002188207P00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00282619OtherRAILROAD
NY5214LBW991Medicare PIN
Q07259Medicare UPIN