Provider Demographics
NPI:1336486752
Name:MIRON, JENNIFER LISCH (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LISCH
Last Name:MIRON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:LISCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7610 N STEMMONS FWY STE 600
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4228
Mailing Address - Country:US
Mailing Address - Phone:214-689-5960
Mailing Address - Fax:469-713-8084
Practice Address - Street 1:8220 WALNUT HILL LN STE 710
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4427
Practice Address - Country:US
Practice Address - Phone:214-368-6707
Practice Address - Fax:214-368-1804
Is Sole Proprietor?:No
Enumeration Date:2013-01-04
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112291363AM0700X
TXPA08252363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical