Provider Demographics
NPI:1043219850
Name:MIRONE, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:MIRONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 PENINSULA DR STE 9
Mailing Address - Street 2:SUITE 9
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-4261
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 PENINSULA DR STE 9
Practice Address - Street 2:SUITE 9
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-4261
Practice Address - Country:US
Practice Address - Phone:814-877-7035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD063285L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2064617OtherOH MEDICAL ASSISTANCE
PA262843OtherBLUE SHIELD
PA82111OtherUNISON
PA0016716180003Medicaid
PA080121102OtherRR MEDICARE
PA205020OtherUPMC
PA1048600OtherAETNA
NY01983980OtherNY MEDICAL ASSISTANCE
NY00025197501OtherUNIVERA
PAP001462OtherGATEWAY
PA0016716180003Medicaid
OH2064617OtherOH MEDICAL ASSISTANCE