Provider Demographics
NPI:1184751745
Name:WOOD, MIRANDA DAWN (PA)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:DAWN
Last Name:WOOD
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 1:854 W JAMES CAMPBELL BLVD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4659
Mailing Address - Country:US
Mailing Address - Phone:931-540-4140
Mailing Address - Fax:931-540-4143
Practice Address - Street 1:1222 TROTWOOD AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-6436
Practice Address - Country:US
Practice Address - Phone:931-540-4140
Practice Address - Fax:931-540-4142
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1592363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1505712Medicaid
4191519OtherBCBST
TN3710089Medicaid
TN1505712Medicaid
TN3710089Medicaid
4191519OtherBCBST