Provider Demographics
NPI:1760731921
Name:MILLER, AMELIA G (PA)
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:G
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 642302
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99164-2302
Mailing Address - Country:US
Mailing Address - Phone:509-335-3575
Mailing Address - Fax:509-335-6223
Practice Address - Street 1:1125 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99164-1018
Practice Address - Country:US
Practice Address - Phone:509-335-3575
Practice Address - Fax:509-335-6223
Is Sole Proprietor?:No
Enumeration Date:2012-09-04
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60800394363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2092688Medicaid