Provider Demographics
NPI:1851627178
Name:MIRANDA, CRYSTAL YOUNG (PA)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:YOUNG
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:400 CELEBRATION PL
Mailing Address - Street 2:
Mailing Address - City:CELEBRATION
Mailing Address - State:FL
Mailing Address - Zip Code:34747-4970
Mailing Address - Country:US
Mailing Address - Phone:407-303-4000
Mailing Address - Fax:
Practice Address - Street 1:400 CELEBRATION PL
Practice Address - Street 2:
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-4970
Practice Address - Country:US
Practice Address - Phone:407-303-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-21
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105266363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01270603OtherRR MEDICARE
FL001550100Medicaid
FLP01270603OtherRR MEDICARE