Provider Demographics
NPI:1902068042
Name:MILLER, KRISTIN B (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:B
Last Name:MILLER
Suffix:
Gender:F
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 1:2350 N LAKE DR
Mailing Address - Street 2:SUITE 206
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-4528
Mailing Address - Country:US
Mailing Address - Phone:414-298-7280
Mailing Address - Fax:414-298-7281
Practice Address - Street 1:2350 N LAKE DR
Practice Address - Street 2:SUITE 206
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4528
Practice Address - Country:US
Practice Address - Phone:414-298-7280
Practice Address - Fax:414-298-7281
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2272363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI420040000Medicaid
WI420040000Medicaid
000002525-0359Medicare PIN
P00794208Medicare PIN