Provider Demographics
NPI:1154538064
Name:MILLER, DESIREE Y (PA-C)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:Y
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DESIREE
Other - Middle Name:Y
Other - Last Name:CRAVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:340 W LINCOLN ST
Mailing Address - Street 2:SUITE#300
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1900
Mailing Address - Country:US
Mailing Address - Phone:618-235-4883
Mailing Address - Fax:618-235-9563
Practice Address - Street 1:340 W LINCOLN ST
Practice Address - Street 2:SUITE#300
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1900
Practice Address - Country:US
Practice Address - Phone:618-235-4883
Practice Address - Fax:618-235-9563
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL682250Medicare ID - Type Unspecified
ILQ25242Medicare UPIN