Healthcare Provider Details

I. General information

NPI: 1538633292
Provider Name (Legal Business Name): FABIAN MIRANDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2019
Last Update Date: 01/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 LAWRENCE EXPY DEPT 282
SANTA CLARA CA
95051-5173
US

IV. Provider business mailing address

710 LAWRENCE EXPY DEPT 282
SANTA CLARA CA
95051-5173
US

V. Phone/Fax

Practice location:
  • Phone: 408-851-2558
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number31768
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: