Provider Demographics
NPI:1720471774
Name:DETORE, MIRANDA K (PA-C)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:K
Last Name:DETORE
Suffix:
Gender:F
Credentials:PA-C
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 2242
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99210-2242
Mailing Address - Country:US
Mailing Address - Phone:509-747-6194
Mailing Address - Fax:509-252-2837
Practice Address - Street 1:217 W CATALDO AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2217
Practice Address - Country:US
Practice Address - Phone:509-747-6194
Practice Address - Fax:509-252-2837
Is Sole Proprietor?:No
Enumeration Date:2015-03-16
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
WAPA60610394363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical