Basic Information
Provider Information | |||||||||
NPI: | 1972959658 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILLER | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | MARGARET | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MCDEVITT | ||||||||
OtherFirstName: | KATHLEEN | ||||||||
OtherMiddleName: | MARGARET | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 301 LIPPINCOTT DR STE 410 | ||||||||
Address2: |   | ||||||||
City: | MARLTON | ||||||||
State: | NJ | ||||||||
PostalCode: | 080534197 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8563550340 | ||||||||
FaxNumber: | 8563550330 | ||||||||
Practice Location | |||||||||
Address1: | 1 BRACE RD STE H | ||||||||
Address2: |   | ||||||||
City: | CHERRY HILL | ||||||||
State: | NJ | ||||||||
PostalCode: | 080342600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8565470389 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2016 | ||||||||
LastUpdateDate: | 09/23/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/23/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 25MP00394800 | NJ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.