Provider Demographics
NPI:1316946866
Name:MILLER, VICTORIA O (PA-C)
Entity type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:O
Last Name:MILLER
Suffix:
Gender:F
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 1:493 PROSPERITY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-5045
Mailing Address - Country:US
Mailing Address - Phone:904-824-5437
Mailing Address - Fax:904-824-7575
Practice Address - Street 1:493 PROSPERITY LAKE DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-5045
Practice Address - Country:US
Practice Address - Phone:904-824-5437
Practice Address - Fax:904-824-7575
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100960363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290572800Medicaid