Provider Demographics
NPI:1780646158
Name:MILLER, RUSSELL J (PA C)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:J
Last Name:MILLER
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 1:1468 TREVORTON RD
Mailing Address - Street 2:
Mailing Address - City:COAL TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:17866-7725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1468 TREVORTON RD
Practice Address - Street 2:
Practice Address - City:COAL TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:17866-7725
Practice Address - Country:US
Practice Address - Phone:570-648-9769
Practice Address - Fax:717-692-2381
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA 001072 L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA 001072 LOtherSTATE LICENSE #
PAMA 001072 LOtherSTATE LICENSE #
PA043345Medicare PIN