Provider Demographics
NPI:1538811138
Name:OBANIANA, MIRANDA JO RISTAU (DPT)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:JO RISTAU
Last Name:OBANIANA
Suffix:
Gender:F
Credentials:DPT
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 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:605-312-9802
Practice Address - Street 1:112 SAINT OLAF AVE S
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:MN
Practice Address - Zip Code:56220-1433
Practice Address - Country:US
Practice Address - Phone:507-223-7277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD2321225100000X
225100000X
MN12331225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist