Provider Demographics
NPI:1386405405
Name:MILLER, DYLAN (PA-C)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
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 1:49 LOVEL CT UNIT A
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-5381
Mailing Address - Country:US
Mailing Address - Phone:702-622-9635
Mailing Address - Fax:
Practice Address - Street 1:111 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-1909
Practice Address - Country:US
Practice Address - Phone:973-877-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
NJ25MP00860300363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical