Basic Information
| Provider Information | |||||||||
| NPI: | 1407255953 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARCUS | ||||||||
| FirstName: | MIRANDA | ||||||||
| MiddleName: | MCGRATH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN, CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2147 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339022147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393437100 | ||||||||
| FaxNumber: | 2393437190 | ||||||||
| Practice Location | |||||||||
| Address1: | 9800 S HEALTHPARK DR STE 205 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339083630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393437130 | ||||||||
| FaxNumber: | 2393437185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2014 | ||||||||
| LastUpdateDate: | 03/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | ARNP9222172 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 013331400 | 05 | FL | MEDICAID |