Provider Demographics
NPI:1508998105
Name:MILLER, RICHARD ANDREW (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ANDREW
Last Name:MILLER
Suffix:
Gender:M
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 1:8600 N. STATE RT 91
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-7832
Mailing Address - Country:US
Mailing Address - Phone:309-691-6616
Mailing Address - Fax:309-691-2943
Practice Address - Street 1:7301 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2017
Practice Address - Country:US
Practice Address - Phone:309-589-5900
Practice Address - Fax:309-689-0312
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001469363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00166686OtherRAILROAD MEDICARE
ILK20214Medicare PIN
ILP24958Medicare UPIN