Provider Demographics
NPI:1033352265
Name:EDGERTON, MIRA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:MIRA
Middle Name:
Last Name:EDGERTON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4397 STONEYCROFT DR
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-2935
Mailing Address - Country:US
Mailing Address - Phone:517-349-0737
Mailing Address - Fax:
Practice Address - Street 1:4397 STONEYCROFT DR
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-2935
Practice Address - Country:US
Practice Address - Phone:517-349-0737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-17
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704092938364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health