Provider Demographics
NPI:1124096953
Name:MILLER, KEVYN J (PA)
Entity type:Individual
Prefix:
First Name:KEVYN
Middle Name:J
Last Name:MILLER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601943
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1943
Mailing Address - Country:US
Mailing Address - Phone:704-512-6850
Mailing Address - Fax:
Practice Address - Street 1:421 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LEEDS
Practice Address - State:MA
Practice Address - Zip Code:01053-9764
Practice Address - Country:US
Practice Address - Phone:413-584-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01620363AM0700X
MA1680363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC3039NMedicare PIN
NCNC3039GMedicare PIN
NCNC3039MMedicare PIN
MAQ11216Medicare UPIN
NCNC3039EMedicare PIN
NCNC3039HMedicare PIN
NCNC3039JMedicare PIN
NCNC3039DMedicare PIN
NCNC3039FMedicare PIN
NCNC3039BMedicare PIN
NC2762001Medicare UPIN
NCNC3039IMedicare PIN
NCNC3039CMedicare PIN
NCNC3039AMedicare PIN
NCNC3039LMedicare PIN