Provider Demographics
NPI:1982154886
Name:CHRISTENSEN, MIRANDA (PA-C)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
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 1:17315 290TH ST
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:IA
Mailing Address - Zip Code:51463-8511
Mailing Address - Country:US
Mailing Address - Phone:712-210-4755
Mailing Address - Fax:
Practice Address - Street 1:305 US-69
Practice Address - Street 2:
Practice Address - City:HUXLEY
Practice Address - State:IA
Practice Address - Zip Code:50124
Practice Address - Country:US
Practice Address - Phone:515-597-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA084412363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant