Provider Demographics
NPI:1790727998
Name:MILLER, CRISTAL (PA-C)
Entity Type:Individual
Prefix:
First Name:CRISTAL
Middle Name:
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 1:615 ELSINORE PL STE 200
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-1457
Mailing Address - Country:US
Mailing Address - Phone:513-834-7063
Mailing Address - Fax:
Practice Address - Street 1:2400 GREATSTONE PT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3274
Practice Address - Country:US
Practice Address - Phone:859-218-5999
Practice Address - Fax:859-257-0670
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA922363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100008020Medicaid
KY7100008020Medicaid
KYPENDINGMedicare ID - Type UnspecifiedMKY