Provider Demographics
NPI:1912753716
Name:CHRISTENSEN, MIRADA GUILD (PA-C)
Entity type:Individual
Prefix:
First Name:MIRADA
Middle Name:GUILD
Last Name:CHRISTENSEN
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 1:302 GLOUCESTER RD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31410-3162
Mailing Address - Country:US
Mailing Address - Phone:912-704-9144
Mailing Address - Fax:
Practice Address - Street 1:519 STEPHENSON AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5969
Practice Address - Country:US
Practice Address - Phone:912-354-9447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-24
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363AM0700X
GA12340363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical