Provider Demographics
NPI:1104563204
Name:NYGAARD, MIRANDA A (PA)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:A
Last Name:NYGAARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:506 1ST AVE SE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-4499
Mailing Address - Country:US
Mailing Address - Phone:605-886-8482
Mailing Address - Fax:605-884-4300
Practice Address - Street 1:511 14TH AVE NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-6811
Practice Address - Country:US
Practice Address - Phone:605-886-8482
Practice Address - Fax:605-884-4332
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-19
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
363A00000X
SD1385363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant