Provider Demographics
NPI:1578768578
Name:MILLER, JENNIFER MAE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MAE
Last Name:MILLER
Suffix:
Gender:F
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 1:14921 STONEGREEN LN
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-9784
Mailing Address - Country:US
Mailing Address - Phone:717-203-9503
Mailing Address - Fax:
Practice Address - Street 1:14921 STONEGREEN LN
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-9784
Practice Address - Country:US
Practice Address - Phone:717-203-9503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03642363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC178X3OtherBC/BS
NC1578768578Medicaid
NCPTAN NCC 145AMedicare PIN