Provider Demographics
NPI:1912251760
Name:MILES, JILLIAN ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:ANN
Last Name:MILES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LIBERTY ST STE 800
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1428
Mailing Address - Country:US
Mailing Address - Phone:502-749-7909
Mailing Address - Fax:502-749-9397
Practice Address - Street 1:908 DUPONT RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207
Practice Address - Country:US
Practice Address - Phone:502-749-7909
Practice Address - Fax:502-749-9397
Is Sole Proprietor?:No
Enumeration Date:2012-11-01
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC161363AM0700X
KYPA1788363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100227320-KOHMGMedicaid
KYK069982-KOHMGOtherKY MEDICARE
KYP01977596-KOHMGOtherRR MEDICARE