Basic Information
| Provider Information | |||||||||
| NPI: | 1093111510 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | KERI | ||||||||
| MiddleName: | LONG | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 303 N CLYDE MORRIS BLVD # 10E | ||||||||
| Address2: | PBFS DEPARTMENT | ||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321142709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862264590 | ||||||||
| FaxNumber: | 3864256197 | ||||||||
| Practice Location | |||||||||
| Address1: | 1165 DUNLAWTON AVE STE 105 | ||||||||
| Address2: | |||||||||
| City: | PORT ORANGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321272924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864254787 | ||||||||
| FaxNumber: | 3864254788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2014 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA 9108344 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 013803400 | 05 | FL | MEDICAID |