Basic Information
| Provider Information | |||||||||
| NPI: | 1548246630 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAUGH | ||||||||
| FirstName: | MIRANDA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CFNP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MIKKELSEN | ||||||||
| OtherFirstName: | MIRANDA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 737 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581220001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012346236 | ||||||||
| FaxNumber: | 7012347332 | ||||||||
| Practice Location | |||||||||
| Address1: | 5002 COWHORN CREEK RD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755039766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036143000 | ||||||||
| FaxNumber: | 9036143525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP113329 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | R28268 | ND | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | R28268 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.