Provider Demographics
NPI:1255906301
Name:PRATT, MIRANDA BROOKE (PA)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:BROOKE
Last Name:PRATT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2166 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-3035
Mailing Address - Country:US
Mailing Address - Phone:865-273-9024
Mailing Address - Fax:
Practice Address - Street 1:1300 OLD WEISGARBER RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-1291
Practice Address - Country:US
Practice Address - Phone:865-584-2146
Practice Address - Fax:865-500-6436
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN4355363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ066090Medicaid