Provider Demographics
NPI:1902858582
Name:MILLER, JENNIFER T (PA)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:T
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:46 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-3845
Mailing Address - Country:US
Mailing Address - Phone:508-771-0006
Mailing Address - Fax:508-790-8337
Practice Address - Street 1:46 NORTH STREET
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601
Practice Address - Country:US
Practice Address - Phone:508-771-0006
Practice Address - Fax:508-790-8337
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA194966363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
002350Medicare UPIN