Provider Demographics
NPI:1508238551
Name:AFSHAR, MIQUELA (CRNA)
Entity Type:Individual
Prefix:
First Name:MIQUELA
Middle Name:
Last Name:AFSHAR
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 S HIGHLAND DR APT 611
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-3579
Mailing Address - Country:US
Mailing Address - Phone:312-720-6212
Mailing Address - Fax:
Practice Address - Street 1:2120 S HIGHLAND DR APT 611
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-3579
Practice Address - Country:US
Practice Address - Phone:312-720-6212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9576529-4406367500000X
UT9576529-8901367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered