Healthcare Provider Details

I. General information

NPI: 1518450477
Provider Name (Legal Business Name): JONATHAN MILLER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 05/26/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 SUMMIT AVE
PROVIDENCE RI
02906-2853
US

IV. Provider business mailing address

125 METRO CENTER BLVD STE 2000
WARWICK RI
02886-1785
US

V. Phone/Fax

Practice location:
  • Phone: 401-793-4480
  • Fax:
Mailing address:
  • Phone: 401-432-2500
  • Fax: 401-921-9212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01059
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: