Provider Demographics
NPI:1467901074
Name:FEZER, MIRANDA (PAC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:FEZER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3517 NW CAMAS MEADOWS DR STE 210
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-6602
Mailing Address - Country:US
Mailing Address - Phone:360-345-3175
Mailing Address - Fax:360-230-4780
Practice Address - Street 1:3517 NW CAMAS MEADOWS DR STE 210
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-6602
Practice Address - Country:US
Practice Address - Phone:360-345-3175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60697855363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1467901074Medicaid
WAP01724334OtherRR MEDICARE WVH
WAG8958210, G8958209Medicare PIN