Provider Demographics
NPI:1134654551
Name:MCKELLAR, MIRANDA S
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:S
Last Name:MCKELLAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:S
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:807 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:NORTON
Mailing Address - State:KS
Mailing Address - Zip Code:67654-1403
Mailing Address - Country:US
Mailing Address - Phone:785-877-3305
Mailing Address - Fax:785-877-3076
Practice Address - Street 1:807 N STATE ST
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:KS
Practice Address - Zip Code:67654-1403
Practice Address - Country:US
Practice Address - Phone:785-877-3305
Practice Address - Fax:785-877-3076
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-41203207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS94-09153OtherKBOHA