Healthcare Provider Details

I. General information

NPI: 1760731921
Provider Name (Legal Business Name): AMELIA G MILLER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2012
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 SE WASHINGTON ST
PULLMAN WA
99164-1018
US

IV. Provider business mailing address

PO BOX 642302
PULLMAN WA
99164-2302
US

V. Phone/Fax

Practice location:
  • Phone: 509-335-3575
  • Fax: 509-335-6223
Mailing address:
  • Phone: 509-335-3575
  • Fax: 509-335-6223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA60800394
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2092688
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: