Provider Demographics
NPI:1568032852
Name:DESANCTIS, MIRANDA (NP-C)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:DESANCTIS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 HOOPER RD
Mailing Address - Street 2:
Mailing Address - City:ENDWELL
Mailing Address - State:NY
Mailing Address - Zip Code:13760-3641
Mailing Address - Country:US
Mailing Address - Phone:607-729-2777
Mailing Address - Fax:
Practice Address - Street 1:333 HOOPER RD
Practice Address - Street 2:
Practice Address - City:ENDWELL
Practice Address - State:NY
Practice Address - Zip Code:13760-3641
Practice Address - Country:US
Practice Address - Phone:607-729-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY677427-1363LS0200X
NY348262363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LS0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY348262OtherLICENSE
NY677427-1OtherLICENSE