Provider Demographics
NPI:1811289259
Name:MILLER, AMANDA (PA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 KENMOOR AVE SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8622
Mailing Address - Country:US
Mailing Address - Phone:616-949-5600
Mailing Address - Fax:616-949-6571
Practice Address - Street 1:655 KENMOOR AVE SE
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8622
Practice Address - Country:US
Practice Address - Phone:616-949-5600
Practice Address - Fax:616-949-6571
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601005922363A00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601005922OtherSTATE LICENSE