Provider Demographics
NPI:1245887645
Name:KELLY MIRANDA PHYSICIAN ASSISTANT INC.
Entity type:Organization
Organization Name:KELLY MIRANDA PHYSICIAN ASSISTANT INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:909-229-6886
Mailing Address - Street 1:12875 CANYONWIND RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-9760
Mailing Address - Country:US
Mailing Address - Phone:909-229-6886
Mailing Address - Fax:
Practice Address - Street 1:26520 CACTUS AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-3927
Practice Address - Country:US
Practice Address - Phone:951-486-5690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty