Provider Demographics
NPI:1700369121
Name:MONROE, MILES (PA-C)
Entity Type:Individual
Prefix:
First Name:MILES
Middle Name:
Last Name:MONROE
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 1:1586 MOORINGS DR # DR11B
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-4257
Mailing Address - Country:US
Mailing Address - Phone:540-848-1096
Mailing Address - Fax:
Practice Address - Street 1:1850 TOWN CENTER PKWY STE 303
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3300
Practice Address - Country:US
Practice Address - Phone:703-810-5202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-11
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1156952207RC0200X
VA0110006407363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine