Provider Demographics
NPI:1497023865
Name:ISOM, MIRANDA SALIB
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:SALIB
Last Name:ISOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 E BELL RD
Mailing Address - Street 2:SUITE 172
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-9306
Mailing Address - Country:US
Mailing Address - Phone:480-443-8400
Mailing Address - Fax:480-443-8697
Practice Address - Street 1:4550 E BELL ROAD
Practice Address - Street 2:SUITE 172
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032
Practice Address - Country:US
Practice Address - Phone:480-443-8400
Practice Address - Fax:480-443-8697
Is Sole Proprietor?:No
Enumeration Date:2011-12-13
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
AZ5110363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant