Basic Information
| Provider Information | |||||||||
| NPI: | 1396903878 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILES | ||||||||
| FirstName: | MAMTA | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 37090 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212973090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032959360 | ||||||||
| FaxNumber: | 7032959369 | ||||||||
| Practice Location | |||||||||
| Address1: | 3600 JOSEPH SIEWICK DR | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220331709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033913129 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2008 | ||||||||
| LastUpdateDate: | 09/14/2011 | ||||||||
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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 | 367500000X | RN1006629 | DC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 6236 | 01 | VA | KAISER | OTHER | K-142-0002 | 01 | VA | CARE FIRST | OTHER |