Provider Demographics
NPI:1770240145
Name:BROWN, MIRIAM GORDON (PA-C)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:GORDON
Last Name:BROWN
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:PO BOX 744786
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4786
Mailing Address - Country:US
Mailing Address - Phone:980-834-9170
Mailing Address - Fax:
Practice Address - Street 1:600 W TRADE ST STE B
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:NC
Practice Address - Zip Code:28034-1543
Practice Address - Country:US
Practice Address - Phone:980-834-9170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-20
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001011700363AM0700X
NC0010-11700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical