Provider Demographics
NPI:1497759930
Name:MILLER, MICHELLE R (PA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
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 1:325 MDG, 340 MAGMOLIA CIR
Mailing Address - Street 2:
Mailing Address - City:TYNDALL, AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32403
Mailing Address - Country:US
Mailing Address - Phone:608-797-6826
Mailing Address - Fax:
Practice Address - Street 1:325 MDG, 340 MAGMOLIA CIR
Practice Address - Street 2:
Practice Address - City:TYNDALL, AFB
Practice Address - State:FL
Practice Address - Zip Code:32403
Practice Address - Country:US
Practice Address - Phone:608-797-6826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1843363AM0700X
WI1349363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41921900Medicaid
WI41921900Medicaid
WIK400298315Medicare PIN