Healthcare Provider Details

I. General information

NPI: 1154845071
Provider Name (Legal Business Name): MARINA ROSE MILLER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 MAIN ST STE 201
SPRINGFIELD MA
01107-1150
US

IV. Provider business mailing address

280 CHESTNUT ST FL 2
SPRINGFIELD MA
01199-1001
US

V. Phone/Fax

Practice location:
  • Phone: 413-794-0900
  • Fax: 413-794-2996
Mailing address:
  • Phone: 413-794-0900
  • Fax: 413-794-2996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA6168
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: