Provider Demographics
NPI:1508023151
Name:CRISTALES, MIRANDA F (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MIRANDA
Middle Name:F
Last Name:CRISTALES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:804 SERVICE RD
Mailing Address - Street 2:A201
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-884-2976
Mailing Address - Fax:517-432-3928
Practice Address - Street 1:4660 S HAGADORN RD
Practice Address - Street 2:#600
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5376
Practice Address - Country:US
Practice Address - Phone:517-267-2460
Practice Address - Fax:517-884-8602
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601005230363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1508023151Medicaid
MI5601005230OtherSTATE LICENSE
MIC36179051Medicare PIN