Provider Demographics
NPI:1023098944
Name:MILLER, TODD T (PA C)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:T
Last Name:MILLER
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4745 OGLETOWN STANTON RD
Mailing Address - Street 2:SUITE 225
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713
Mailing Address - Country:US
Mailing Address - Phone:302-731-2888
Mailing Address - Fax:302-731-7049
Practice Address - Street 1:4745 OGLETOWN STANTON RD
Practice Address - Street 2:SUITE 225
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713
Practice Address - Country:US
Practice Address - Phone:302-731-2888
Practice Address - Fax:302-731-7049
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC50000239363A00000X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0001012201Medicaid
DE0001012201Medicaid
R15867Medicare UPIN