Provider Demographics
NPI:1003857830
Name:JOHNSTON, MIRANDA C (PA)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:C
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2057 WHITE MYRTLE DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70447-9480
Mailing Address - Country:US
Mailing Address - Phone:985-259-0822
Mailing Address - Fax:
Practice Address - Street 1:281 W 4TH ST
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:LA
Practice Address - Zip Code:70443-2386
Practice Address - Country:US
Practice Address - Phone:985-878-0066
Practice Address - Fax:985-878-0626
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.A10528.RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAQ43481Medicare UPIN
LA5C788P664Medicare ID - Type Unspecified