Provider Demographics
NPI:1811936800
Name:MILLER, ELIZABETH KATHLEEN (PA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:KATHLEEN
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:K
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:1420 STEPHENSON HWY
Mailing Address - Street 2:SUITE 400- CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1189
Mailing Address - Country:US
Mailing Address - Phone:248-581-5977
Mailing Address - Fax:248-581-5640
Practice Address - Street 1:31995 NORTHWESTERN HWY
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-1625
Practice Address - Country:US
Practice Address - Phone:248-538-4701
Practice Address - Fax:248-538-6545
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00390363A00000X
MI5601006414363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2765895Medicare PIN
MI0P32070043Medicare PIN