Provider Demographics
NPI:1588901573
Name:MILLER, LAUREN (PA)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 SOUTHEAST PKWY STE 105
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-3600
Mailing Address - Country:US
Mailing Address - Phone:817-238-0735
Mailing Address - Fax:817-238-7327
Practice Address - Street 1:909 SOUTHEAST PKWY STE 105
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-3600
Practice Address - Country:US
Practice Address - Phone:817-238-0735
Practice Address - Fax:817-238-7327
Is Sole Proprietor?:No
Enumeration Date:2013-01-10
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08236363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX278715YKPWMedicare PIN