Provider Demographics
NPI:1760770960
Name:DETHIER, MIRANDA R (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:R
Last Name:DETHIER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MIRANDA
Other - Middle Name:RAE
Other - Last Name:GORDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-0249
Mailing Address - Country:US
Mailing Address - Phone:920-568-5411
Mailing Address - Fax:920-568-4004
Practice Address - Street 1:840 W RACINE ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549-1053
Practice Address - Country:US
Practice Address - Phone:920-674-6000
Practice Address - Fax:920-674-3034
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2758-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1760770960Medicaid
WIK400269191Medicare PIN
WIK400269189Medicare PIN