Provider Demographics
NPI:1326334814
Name:HALEY, MIRANDA C (MD)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:C
Last Name:HALEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:
Practice Address - Street 1:117 CAMINO DE VIDA
Practice Address - Street 2:SUITE 300
Practice Address - City:SANTA ROSA
Practice Address - State:NM
Practice Address - Zip Code:88435-2267
Practice Address - Country:US
Practice Address - Phone:575-472-4311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2014-0107207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM96507021Medicaid
NM96507021Medicaid