Provider Demographics
NPI:1598896953
Name:MILES, JOHN BRENT (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:BRENT
Last Name:MILES
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 1:3400 DATA DR
Mailing Address - Street 2:PHYSICIAN SUPPORT SERVICES
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:916-379-2948
Mailing Address - Fax:916-858-7065
Practice Address - Street 1:6555 COYLE AVENUE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608
Practice Address - Country:US
Practice Address - Phone:916-536-3670
Practice Address - Fax:916-536-2480
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05080363A00000X, 363AS0400X
CAPA22162363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA22162OtherPHYSICIAN ASSISTANT LICENSE
TXPA05080OtherPA LICENSE
CAPENDINGMedicare PIN