Provider Demographics
NPI:1114382694
Name:COSTA, MIRANDA J (ND)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:J
Last Name:COSTA
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430 SE 67TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-1215
Mailing Address - Country:US
Mailing Address - Phone:541-778-4130
Mailing Address - Fax:
Practice Address - Street 1:2430 SE 67TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-1215
Practice Address - Country:US
Practice Address - Phone:541-778-4130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3058175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath