Provider Demographics
NPI:1134910169
Name:MIRANDA, MARCO ANTONIO II
Entity type:Individual
Prefix:MR
First Name:MARCO
Middle Name:ANTONIO
Last Name:MIRANDA
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 S 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-2927
Mailing Address - Country:US
Mailing Address - Phone:928-287-6123
Mailing Address - Fax:
Practice Address - Street 1:618 S 10TH AVE
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-2927
Practice Address - Country:US
Practice Address - Phone:928-287-6123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-17
Last Update Date:2025-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ323362363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health