Provider Demographics
NPI:1326386509
Name:MIRACLE, NATHAN A (PA-C)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:A
Last Name:MIRACLE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 E RIVER BLUFF BLVD
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-8807
Mailing Address - Country:US
Mailing Address - Phone:417-820-5610
Mailing Address - Fax:
Practice Address - Street 1:3050 E RIVER BLUFF BLVD
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721
Practice Address - Country:US
Practice Address - Phone:417-820-5610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-23
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013001193363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical