Healthcare Provider Details

I. General information

NPI: 1891422937
Provider Name (Legal Business Name): MIAH MARIE FORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 N 12TH ST
MILWAUKEE WI
53233-1305
US

IV. Provider business mailing address

820 S 91ST ST
WEST ALLIS WI
53214-2845
US

V. Phone/Fax

Practice location:
  • Phone: 414-219-2000
  • Fax:
Mailing address:
  • Phone: 319-215-5932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7645-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: