Provider Demographics
NPI:1760986624
Name:MILLER, DIANDRA SHAKIRA (PA-C)
Entity Type:Individual
Prefix:
First Name:DIANDRA
Middle Name:SHAKIRA
Last Name:MILLER
Suffix:
Gender:F
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 1:3580 ARCADE ST
Mailing Address - Street 2:
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55127-7135
Mailing Address - Country:US
Mailing Address - Phone:651-968-5600
Mailing Address - Fax:
Practice Address - Street 1:3580 ARCADE ST
Practice Address - Street 2:
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55127
Practice Address - Country:US
Practice Address - Phone:651-968-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12686363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant