Healthcare Provider Details

I. General information

NPI: 1891107488
Provider Name (Legal Business Name): JASON MIRANDA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2014
Last Update Date: 05/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 E STRAWBRIDGE AVE
MELBOURNE FL
32901-4732
US

IV. Provider business mailing address

3049 LINDALE AVE
ORLANDO FL
32814-6770
US

V. Phone/Fax

Practice location:
  • Phone: 321-837-3820
  • Fax: 321-837-3654
Mailing address:
  • Phone: 352-665-2892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9292247
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: