Provider Demographics
NPI:1790841435
Name:MILLER, GRACIELA (PAC)
Entity Type:Individual
Prefix:
First Name:GRACIELA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:GRACIELA
Other - Middle Name:
Other - Last Name:RUIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:602 N EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-3224
Mailing Address - Country:US
Mailing Address - Phone:909-391-3423
Mailing Address - Fax:
Practice Address - Street 1:420 W ROWLAND ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-2943
Practice Address - Country:US
Practice Address - Phone:626-331-6411
Practice Address - Fax:626-251-1560
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT63709531206363A00000X
CAPA20400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant