Provider Demographics
NPI:1649425091
Name:POOL, MIRANDA JALENE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MS
First Name:MIRANDA
Middle Name:JALENE
Last Name:POOL
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
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Mailing Address - Street 1:17819 RED RIVER CANYON DR
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77346-3543
Mailing Address - Country:US
Mailing Address - Phone:832-810-0200
Mailing Address - Fax:888-682-7273
Practice Address - Street 1:1300 SOUTH DRIVE
Practice Address - Street 2:
Practice Address - City:WINNEBAGO
Practice Address - State:WI
Practice Address - Zip Code:54985-5498
Practice Address - Country:US
Practice Address - Phone:920-235-4910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-26
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX63151101YP2500X
TX363A00000X
WI4641363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional