Provider Demographics
NPI:1003547670
Name:MIRANDA, IVAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:IVAN
Other - Middle Name:
Other - Last Name:MIRANDA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MPAS, PA-C
Mailing Address - Street 1:16479 DALLAS PKWY STE 320
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-6709
Mailing Address - Country:US
Mailing Address - Phone:469-484-4260
Mailing Address - Fax:469-484-4265
Practice Address - Street 1:16479 DALLAS PKWY STE 320
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-6709
Practice Address - Country:US
Practice Address - Phone:469-484-4260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA17718363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical