Healthcare Provider Details

I. General information

NPI: 1457032674
Provider Name (Legal Business Name): MR. JONATHAN GARY MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N MAPLEMERE RD STE 100
WILLIAMSVILLE NY
14221-3182
US

IV. Provider business mailing address

4225 GENESEE ST STE 400
CHEEKTOWAGA NY
14225-1994
US

V. Phone/Fax

Practice location:
  • Phone: 716-204-3200
  • Fax: 716-204-4337
Mailing address:
  • Phone: 167-204-3200
  • Fax: 716-204-4337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number031096
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: