Provider Demographics
NPI:1487042206
Name:SWANSON, MIRANDA (ATC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:SWANSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10126 11TH ST NE
Mailing Address - Street 2:
Mailing Address - City:SPICER
Mailing Address - State:MN
Mailing Address - Zip Code:56288-9427
Mailing Address - Country:US
Mailing Address - Phone:763-229-9773
Mailing Address - Fax:
Practice Address - Street 1:101 WILLMAR AVE SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3556
Practice Address - Country:US
Practice Address - Phone:763-229-9773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-31
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer