Healthcare Provider Details

I. General information

NPI: 1467287565
Provider Name (Legal Business Name): ELISE M MILLER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2024
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 HARRISON AVENUE STE 1400
BOSTON MA
02118
US

IV. Provider business mailing address

960 MASSACHUSETTS AVE FL 2
BOSTON MA
02118-2690
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-8124
  • Fax: 617-414-4953
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA101141
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: