Provider Demographics
NPI:1760087373
Name:MILLER, ISAAC LEE (PTA)
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:LEE
Last Name:MILLER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1323 IRVING ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5040
Mailing Address - Country:US
Mailing Address - Phone:336-345-9282
Mailing Address - Fax:
Practice Address - Street 1:1199 HAYES FOREST DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3377
Practice Address - Country:US
Practice Address - Phone:336-759-1044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA7257225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant