Provider Demographics
NPI:1639607070
Name:PELZEL, MIRANDA LEIGH (APRN)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LEIGH
Last Name:PELZEL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 S TEXAS AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-5361
Mailing Address - Country:US
Mailing Address - Phone:936-266-3513
Mailing Address - Fax:713-852-2332
Practice Address - Street 1:2700 E 29TH ST STE 240
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2586
Practice Address - Country:US
Practice Address - Phone:979-776-0750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2016038173363LA2100X
FLAPRN11002524363LA2100X
TX1088064363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1639607070Medicaid
TX1088064OtherTEXAS APRN