Provider Demographics
NPI:1992145197
Name:MILLER, JONATHAN L (PA-C)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:L
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:PO BOX 9000
Mailing Address - Street 2:SPRINGFIELD TECHNICAL COMMUNITY COLLEGE
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01102-9000
Mailing Address - Country:US
Mailing Address - Phone:413-755-4385
Mailing Address - Fax:413-755-6045
Practice Address - Street 1:1 ARMORY SQ
Practice Address - Street 2:SPRINGFIELD TECHNICAL COMMUNITY COLLEGE
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-1700
Practice Address - Country:US
Practice Address - Phone:413-755-4385
Practice Address - Fax:413-755-6045
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA920390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program