Provider Demographics
NPI:1083190698
Name:MIRANDA, LACEY ASHTON (PA)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:ASHTON
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:770-219-8440
Practice Address - Street 1:1075 JESSE JEWELL PKWY NE STE B
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3814
Practice Address - Country:US
Practice Address - Phone:770-219-9200
Practice Address - Fax:770-219-9274
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-17
Last Update Date:2018-09-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA008939363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical