Basic Information
| Provider Information | |||||||||
| NPI: | 1669559795 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | LYNDELL | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GEORGE | ||||||||
| OtherFirstName: | CHRISTINA | ||||||||
| OtherMiddleName: | LYNDELL | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 307 S EVERGREEN AVE | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080962739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6093647157 | ||||||||
| FaxNumber: | 8656925900 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 N JAMES ST | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134402844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286876282 | ||||||||
| FaxNumber: | 8286876285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1460 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 020563 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | J400370502 | 01 | NY | MEDICARE PTAN | OTHER |