Provider Demographics
NPI:1821064932
Name:MIRANDA, MARIA ROWENA D (NP)
Entity Type:Individual
Prefix:
First Name:MARIA ROWENA
Middle Name:D
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 409041
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-9041
Mailing Address - Country:US
Mailing Address - Phone:800-377-8721
Mailing Address - Fax:304-523-2241
Practice Address - Street 1:150 55TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-2559
Practice Address - Country:US
Practice Address - Phone:718-630-7185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332852-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02075634Medicaid
NY1094G1OtherBLUECROSS BLUESHIELD
P04040Medicare UPIN
NY02075634Medicaid