Provider Demographics
NPI:1891107488
Name:MIRANDA, JASON (CRNA)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3049 LINDALE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-6770
Mailing Address - Country:US
Mailing Address - Phone:352-665-2892
Mailing Address - Fax:
Practice Address - Street 1:520 E STRAWBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-4732
Practice Address - Country:US
Practice Address - Phone:321-837-3820
Practice Address - Fax:321-837-3654
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-30
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9292247367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered