Basic Information
| Provider Information | |||||||||
| NPI: | 1528184116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILES | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C, PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 17 LANSING ST | ||||||||
| Address2: | AMMS, PC CREDENTIALING OFFICE | ||||||||
| City: | AUBURN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130211983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152557438 | ||||||||
| FaxNumber: | 3152557099 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 E GENESEE ST | ||||||||
| Address2: | SUITE #101 | ||||||||
| City: | AUBURN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130214040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152535151 | ||||||||
| FaxNumber: | 3152530841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 07/16/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 13066 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 363AS0400X | 013624 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 02399411 | 05 | NY | MEDICAID |