Provider Demographics
NPI:1962740654
Name:MIRACHI, NINA ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:ELIZABETH
Last Name:MIRACHI
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 1:3803 W CHESTER PIKE STE 160
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-2336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:255 W LANCASTER AVE
Practice Address - Street 2:SUITE 201, MOB 1
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1763
Practice Address - Country:US
Practice Address - Phone:484-476-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-30
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057407363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031551180007Medicaid