Provider Demographics
NPI:1396067393
Name:EVERETT, MIRANDA ESTELLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:ESTELLE
Last Name:EVERETT
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 1:6425 LYNCH CANYON DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ISABELLA
Mailing Address - State:CA
Mailing Address - Zip Code:93240-9726
Mailing Address - Country:US
Mailing Address - Phone:760-379-8630
Mailing Address - Fax:
Practice Address - Street 1:6425 LYNCH CANYON DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN MESA
Practice Address - State:CA
Practice Address - Zip Code:93240-9726
Practice Address - Country:US
Practice Address - Phone:760-379-8630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA20846OtherSTATE LICENSE