Provider Demographics
NPI:1912297821
Name:MILLER, COURTNEY A (PA-C)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:A
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:A
Other - Last Name:VAN FLEET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:230 CLEARFIELD AVE
Mailing Address - Street 2:SUITE 124
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1832
Mailing Address - Country:US
Mailing Address - Phone:757-321-3383
Mailing Address - Fax:757-321-3332
Practice Address - Street 1:1800 CAMELOT DR
Practice Address - Street 2:SUITE 300
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2440
Practice Address - Country:US
Practice Address - Phone:757-321-3383
Practice Address - Fax:757-321-3332
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003743363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA541869550OtherTRICARE
VA1912297821Medicaid
VAVV5055AMedicare PIN