Provider Demographics
NPI:1265871545
Name:FELTY, MIRANDA JEAN
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:JEAN
Last Name:FELTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6130 SPRINGFORD DR APT J6
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17111-6876
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 S 17TH ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17104-1123
Practice Address - Country:US
Practice Address - Phone:717-232-9971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-19
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056148363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical