Basic Information
| Provider Information | |||||||||
| NPI: | 1861992265 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | MARGARET | ||||||||
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| Credential: | MPAS, PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 33369 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282333369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043648100 | ||||||||
| FaxNumber: | 7043652073 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 VAIL AVE STE 320 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282071222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043006769 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2018 | ||||||||
| LastUpdateDate: | 02/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-07900 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.