Provider Demographics
NPI:1669107512
Name:TADEVICH, MIRANDA
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:TADEVICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:DOWNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 255228
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-5228
Mailing Address - Country:US
Mailing Address - Phone:209-830-4075
Mailing Address - Fax:
Practice Address - Street 1:445 W EATON AVE
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3420
Practice Address - Country:US
Practice Address - Phone:209-830-4075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-22
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0997765363L00000X
CANP95029206363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner