Provider Demographics
NPI:1144848912
Name:HUENERS, MIRANDA (OD)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:HUENERS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 LAKESIDE CT STE 103
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-7305
Mailing Address - Country:US
Mailing Address - Phone:509-453-2010
Mailing Address - Fax:
Practice Address - Street 1:1410 LAKESIDE CT STE 103
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-7305
Practice Address - Country:US
Practice Address - Phone:509-453-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002436152W00000X
WA61116371152W00000X
WAOD61116371152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA300117730Medicaid
WAOD61116371OtherSTATE LICENSE