Provider Demographics
NPI:1225697147
Name:MIRANDA, CHRISTIAN RICARDO (DPT)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:RICARDO
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8833 SW 30TH AVE APT 116
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-4066
Mailing Address - Country:US
Mailing Address - Phone:503-422-7816
Mailing Address - Fax:
Practice Address - Street 1:200 S HAZEL DELL WAY STE 210
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-7828
Practice Address - Country:US
Practice Address - Phone:503-263-9550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR632692251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic