Provider Demographics
NPI:1821413766
Name:MCGAHAN, MIRANDA RAE-TSUKAMOTO (DO)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:RAE-TSUKAMOTO
Last Name:MCGAHAN
Suffix:
Gender:F
Credentials:DO
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NC
Practice Address - Zip Code:28120-1620
Practice Address - Country:US
Practice Address - Phone:704-587-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-01
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2017-01933207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1821413766Medicaid