Provider Demographics
NPI:1942895701
Name:AYERS-BURKGREN, MIRANDA JAYE (PA)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:JAYE
Last Name:AYERS-BURKGREN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1591 MCKIMBER DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:50138-8800
Mailing Address - Country:US
Mailing Address - Phone:515-971-3804
Mailing Address - Fax:
Practice Address - Street 1:3200 GRAND AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-4104
Practice Address - Country:US
Practice Address - Phone:515-271-1569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-03
Last Update Date:2022-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IA114134363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program