Provider Demographics
NPI:1033722822
Name:MIRANDA, NATALIE
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 HENSHAW ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-2927
Mailing Address - Country:US
Mailing Address - Phone:860-483-1633
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST # STREET1
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-643-0045
Practice Address - Fax:617-726-7415
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA7781363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant