Provider Demographics
NPI:1598137085
Name:MIRANDA, KARINA J (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KARINA
Middle Name:J
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W FULTON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-1262
Mailing Address - Country:US
Mailing Address - Phone:312-526-2083
Mailing Address - Fax:312-526-2083
Practice Address - Street 1:8321 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1605
Practice Address - Country:US
Practice Address - Phone:708-681-2298
Practice Address - Fax:708-681-2398
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-23
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005705363AM0700X
IL085-005705363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085.005705OtherPHYSICIAN ASSISTANT LICENSE