Provider Demographics
NPI:1942586573
Name:MCMINN, MIRANDA L
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:L
Last Name:MCMINN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6029 WALNUT GROVE RD STE 401
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2112
Mailing Address - Country:US
Mailing Address - Phone:901-747-3066
Mailing Address - Fax:901-747-2966
Practice Address - Street 1:6029 WALNUT GROVE RD STE 401
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2112
Practice Address - Country:US
Practice Address - Phone:901-747-3066
Practice Address - Fax:901-747-2966
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3803246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist