Healthcare Provider Details

I. General information

NPI: 1982305462
Provider Name (Legal Business Name): MAURICIO JUNIOR MIRANDA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4309 W MEDICAL CENTER DR STE A200
MCHENRY IL
60050-8437
US

IV. Provider business mailing address

4309 W MEDICAL CENTER DR STE A200
MCHENRY IL
60050-8437
US

V. Phone/Fax

Practice location:
  • Phone: 815-759-8070
  • Fax: 815-759-4931
Mailing address:
  • Phone: 815-759-8070
  • Fax: 815-759-4931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085009878
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: