Provider Demographics
NPI:1124073002
Name:MIRANDA, AMY M (CRNA)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:M
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-2297
Mailing Address - Country:US
Mailing Address - Phone:717-637-3711
Mailing Address - Fax:
Practice Address - Street 1:300 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331-2297
Practice Address - Country:US
Practice Address - Phone:717-637-3711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR134791163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
053380OtherNATIONAL CRNA
MDM653066603025OtherLICENSE