Provider Demographics
NPI:1336914084
Name:MIRANDA, JERRALD EPAN (DPT)
Entity Type:Individual
Prefix:
First Name:JERRALD
Middle Name:EPAN
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 PARIS ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94112-3512
Mailing Address - Country:US
Mailing Address - Phone:415-845-7255
Mailing Address - Fax:
Practice Address - Street 1:302 SILVER AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94112-1510
Practice Address - Country:US
Practice Address - Phone:415-334-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA305102225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist