Provider Demographics
NPI:1295356079
Name:CARTER, MIRANDA (PTA)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:CARTER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1226 7TH ST
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98337-1251
Mailing Address - Country:US
Mailing Address - Phone:360-473-3953
Mailing Address - Fax:
Practice Address - Street 1:3015 LIMITED LN NW STE B
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-2638
Practice Address - Country:US
Practice Address - Phone:360-709-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-02
Last Update Date:2020-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60936094225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant