Provider Demographics
NPI:1609152479
Name:MILLER, MANDIE (MMS, PA-C)
Entity Type:Individual
Prefix:
First Name:MANDIE
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:MMS, PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MMS, PA-C
Mailing Address - Street 1:17505 N 79TH AVE STE 407
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8732
Mailing Address - Country:US
Mailing Address - Phone:623-321-2221
Mailing Address - Fax:855-397-2676
Practice Address - Street 1:17505 N 79TH AVE STE 407
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8732
Practice Address - Country:US
Practice Address - Phone:623-321-2221
Practice Address - Fax:855-397-2676
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4918363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical