Provider Demographics
NPI:1043540966
Name:MCDONALD, MIRANDA (LAC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 W 78TH ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-4524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:470 W 78TH ST
Practice Address - Street 2:SUITE 120
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-4524
Practice Address - Country:US
Practice Address - Phone:952-949-0676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1509171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist