Provider Demographics
NPI:1164946869
Name:MIRGON, KEIRSTAN
Entity Type:Individual
Prefix:
First Name:KEIRSTAN
Middle Name:
Last Name:MIRGON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6180 MIRGON RD
Mailing Address - Street 2:
Mailing Address - City:SUGAR GROVE
Mailing Address - State:OH
Mailing Address - Zip Code:43155-9779
Mailing Address - Country:US
Mailing Address - Phone:740-415-7245
Mailing Address - Fax:
Practice Address - Street 1:6180 MIRGON RD
Practice Address - Street 2:
Practice Address - City:SUGAR GROVE
Practice Address - State:OH
Practice Address - Zip Code:43155-9779
Practice Address - Country:US
Practice Address - Phone:740-415-7245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH924738597271OtherMEDICAL MUTUAL