Healthcare Provider Details

I. General information

NPI: 1629045513
Provider Name (Legal Business Name): RAISA MILLER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91550 OVERSEAS HWY STE 205
TAVERNIER FL
33070-2513
US

IV. Provider business mailing address

PO BOX 100707
ATLANTA GA
30384-0707
US

V. Phone/Fax

Practice location:
  • Phone: 305-434-3400
  • Fax: 786-260-0513
Mailing address:
  • Phone: 305-434-3400
  • Fax: 786-260-0513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9102221
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9102221
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: