Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | AP08525 | LA |
NPI | 1003285057 |
---|---|
Provider Name | Megan Miranda |
First Address | La Place, LA 70068-6451 |
Second Address | La Place, LA 70068-5505 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/09/2015 |
Last Update Date | 24/02/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01505763 | (05) | MS |
2405217 | (05) | LA |