Healthcare Provider Details

I. General information

NPI: 1942895701
Provider Name (Legal Business Name): MIRANDA JAYE AYERS-BURKGREN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2021
Last Update Date: 08/28/2022
Certification Date: 08/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 GRAND AVE
DES MOINES IA
50312-4104
US

IV. Provider business mailing address

1591 MCKIMBER DR
KNOXVILLE IA
50138-8800
US

V. Phone/Fax

Practice location:
  • Phone: 515-271-1569
  • Fax:
Mailing address:
  • Phone: 515-971-3804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number114134
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: