Basic Information
| Provider Information | |||||||||
| NPI: | 1245887645 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KELLY MIRANDA PHYSICIAN ASSISTANT INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12875 CANYONWIND RD | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925039760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092296886 | ||||||||
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| Practice Location | |||||||||
| Address1: | 26520 CACTUS AVE | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925553927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514865690 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2019 | ||||||||
| LastUpdateDate: | 08/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | MIRANDA | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 9092296886 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | PA-C | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.