Provider Demographics
NPI:1902387202
Name:MIRANDA, MATT M (PTA)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:M
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 N LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-2109
Mailing Address - Country:US
Mailing Address - Phone:609-332-3908
Mailing Address - Fax:
Practice Address - Street 1:1919 CHESTNUT ST STE 104
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-3456
Practice Address - Country:US
Practice Address - Phone:215-564-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE011900225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant