Provider Demographics
NPI:1619601671
Name:PERSAUD, MIRANDA KAVITA (PA-C)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:KAVITA
Last Name:PERSAUD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6710 COLLINS RD APT 2509
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-5888
Mailing Address - Country:US
Mailing Address - Phone:754-422-6886
Mailing Address - Fax:
Practice Address - Street 1:3750 SAN JOSE PL STE 35
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-8861
Practice Address - Country:US
Practice Address - Phone:904-902-4126
Practice Address - Fax:904-902-3926
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9115776363A00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL202248493Medicaid