Provider Demographics
NPI:1104000595
Name:MILFORT, MIRANDA DELORIS (PA)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:DELORIS
Last Name:MILFORT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 STOCKER ST
Mailing Address - Street 2:STE. 105
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-5108
Mailing Address - Country:US
Mailing Address - Phone:310-908-9121
Mailing Address - Fax:
Practice Address - Street 1:3701 STOCKER ST
Practice Address - Street 2:STE. 105
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-5108
Practice Address - Country:US
Practice Address - Phone:323-295-0644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15167363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant