Provider Demographics
NPI:1356422745
Name:MIRANDA, KENDRA LASONIA (PA)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:LASONIA
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 415933
Mailing Address - Street 2:HARTFORD HOSPITAL PROFESSSIONAL SERVICES
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5933
Mailing Address - Country:US
Mailing Address - Phone:860-545-7602
Mailing Address - Fax:
Practice Address - Street 1:80 SEYMOUR ST
Practice Address - Street 2:HARTFORD HOSPITAL SURGERY DEPT - CRITICAL CARE
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06102-8000
Practice Address - Country:US
Practice Address - Phone:860-545-4670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001495363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003014958Medicaid
CT003014958Medicaid
CT970001770Medicare ID - Type UnspecifiedFOR CLINIC C00814