Provider Demographics
NPI:1588637185
Name:MILLER, JEANETTE C (PA C)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:C
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1406 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-255-5656
Mailing Address - Fax:320-656-7044
Practice Address - Street 1:1406 6TH AVE N
Practice Address - Street 2:ST CLOUD HOSPITAL ETC
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-255-5656
Practice Address - Fax:320-656-7044
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN9318363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S55642Medicare UPIN