Provider Demographics
NPI:1285499236
Name:SWANBERG, MIRANDA N (PA-C)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:N
Last Name:SWANBERG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99213
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0213
Mailing Address - Country:US
Mailing Address - Phone:682-885-1860
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:1401 W PULASKI ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2717
Practice Address - Country:US
Practice Address - Phone:682-885-8012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TXPA17947363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant