Healthcare Provider Details

I. General information

NPI: 1912168964
Provider Name (Legal Business Name): ELISA R MILLER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 12/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 POPLAR ST
MURRAY KY
42071-2432
US

IV. Provider business mailing address

1431 CENTERPOINT BLVD SUITE 100
KNOXVILLE TN
37932-1984
US

V. Phone/Fax

Practice location:
  • Phone: 270-762-1100
  • Fax:
Mailing address:
  • Phone: 865-985-7068
  • Fax: 865-985-7077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPENDING
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: