Provider Demographics
NPI:1649053141
Name:HERNANDEZ, MIRANDA SANTANA
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:SANTANA
Last Name:HERNANDEZ
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 1:100 N BRENT ST STE 201
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-2835
Mailing Address - Country:US
Mailing Address - Phone:805-643-3330
Mailing Address - Fax:
Practice Address - Street 1:100 N BRENT ST STE 201
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2835
Practice Address - Country:US
Practice Address - Phone:805-643-3330
Practice Address - Fax:805-643-3331
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-17
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant