Provider Demographics
NPI:1629036108
Name:MILLER, LISA ALISON (PAC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ALISON
Last Name:MILLER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 S MAIN ST STE 102
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-4864
Mailing Address - Country:US
Mailing Address - Phone:724-837-2112
Mailing Address - Fax:724-691-0864
Practice Address - Street 1:1075 S MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601
Practice Address - Country:US
Practice Address - Phone:724-837-2112
Practice Address - Fax:724-691-0864
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051690207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA080062ELMMedicare ID - Type Unspecified
Q17572Medicare UPIN