Provider Demographics
NPI:1114627783
Name:MILLER, KRISTINE (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:MILLER
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5338 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-3138
Mailing Address - Country:US
Mailing Address - Phone:810-614-2014
Mailing Address - Fax:
Practice Address - Street 1:9934 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-3040
Practice Address - Country:US
Practice Address - Phone:866-434-3255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-03
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003939A363A00000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant