Healthcare Provider Details

I. General information

NPI: 1790221786
Provider Name (Legal Business Name): MIRANDA POMIJE ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2017
Last Update Date: 01/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2351 HUDSON ROAD UNIVERSITY OF NORTHERN IOWA- ATHLETIC TRAINING
CEDAR FALLS IA
50613
US

IV. Provider business mailing address

1614 PARKER ST
CEDAR FALLS IA
50613-4627
US

V. Phone/Fax

Practice location:
  • Phone: 319-273-2311
  • Fax:
Mailing address:
  • Phone: 952-594-1104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number078761
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: