Provider Demographics
NPI:1881646529
Name:MIRANDA, AZALIA (PT)
Entity Type:Individual
Prefix:MRS
First Name:AZALIA
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:AZALIA
Other - Middle Name:
Other - Last Name:MIRANDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 15310
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34277-1310
Mailing Address - Country:US
Mailing Address - Phone:941-749-1734
Mailing Address - Fax:941-749-1736
Practice Address - Street 1:2990 US HIGHWAY 301 N
Practice Address - Street 2:
Practice Address - City:ELLENTON
Practice Address - State:FL
Practice Address - Zip Code:34222-2008
Practice Address - Country:US
Practice Address - Phone:941-721-1854
Practice Address - Fax:941-721-1859
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT22305225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL883054100Medicaid
FL883054100Medicaid