Provider Demographics
NPI:1891705885
Name:GAW, MIRANDA PWEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:PWEN
Last Name:GAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1669 W AVE J, SUITE 304
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534
Mailing Address - Country:US
Mailing Address - Phone:661-951-7888
Mailing Address - Fax:661-951-8889
Practice Address - Street 1:1669 W AVENUE J STE 304
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2870
Practice Address - Country:US
Practice Address - Phone:661-951-7888
Practice Address - Fax:661-951-8889
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2014-06-24
Deactivation Date:2006-08-22
Deactivation Code:
Reactivation Date:2006-09-15
Provider Licenses
StateLicense IDTaxonomies
CAA52438207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A524380Medicaid
CA00A524380Medicaid
CAWA52438AMedicare ID - Type Unspecified