Provider Demographics
NPI:1124281951
Name:MICLAY, JANE LENORE (PA-C)
Entity type:Individual
Prefix:MS
First Name:JANE
Middle Name:LENORE
Last Name:MICLAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:203 HOSPITAL DR
Mailing Address - Street 2:SUITE B100
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-6904
Mailing Address - Country:US
Mailing Address - Phone:410-553-8351
Mailing Address - Fax:410-553-8352
Practice Address - Street 1:203 HOSPITAL DR
Practice Address - Street 2:SUITE B100
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-6904
Practice Address - Country:US
Practice Address - Phone:410-553-8351
Practice Address - Fax:410-553-8352
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003683363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD406923400Medicaid
MD165719ZEZJMedicare PIN