Provider Demographics
NPI:1992727051
Name:MILLER, JASON R (PA)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:MILLER
Suffix:
Gender:M
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:PO BOX 7848
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-0848
Mailing Address - Country:US
Mailing Address - Phone:757-397-0783
Mailing Address - Fax:757-397-0236
Practice Address - Street 1:3300 HIGH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3321
Practice Address - Country:US
Practice Address - Phone:757-397-0783
Practice Address - Fax:757-397-0236
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001952363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010239770Medicaid
VAP00799175OtherRR MEDICARE
VAP00193130OtherMEDICARE RR
VAP00799175OtherRR MEDICARE
VAP72137Medicare UPIN
VA006634O04Medicare PIN