Provider Demographics
NPI:1831143866
Name:MILLER, TAMARA L (PA)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:L
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 1:333 MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4814
Mailing Address - Country:US
Mailing Address - Phone:715-833-9515
Mailing Address - Fax:
Practice Address - Street 1:CREST WELLNESS CENTER
Practice Address - Street 2:UNIVERSITY OF WISCONSIN:EAU CLAIRE
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6101
Practice Address - Country:US
Practice Address - Phone:715-836-4311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1937363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41971200Medicaid
WI0565 20195Medicare PIN
P21765Medicare UPIN