Provider Demographics
NPI:1245742352
Name:LONG, MIRANDA C (PA)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:C
Last Name:LONG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:C
Other - Last Name:TELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 E MILLER RD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:61081-1252
Mailing Address - Country:US
Mailing Address - Phone:815-625-4790
Mailing Address - Fax:
Practice Address - Street 1:101 E MILLER RD
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-1252
Practice Address - Country:US
Practice Address - Phone:815-625-4790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.006398207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine