Healthcare Provider Details

I. General information

NPI: 1295699593
Provider Name (Legal Business Name): MR. MASON SCOTT MIRANDA I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 N KANSAS ST
WICHITA KS
67214-3124
US

IV. Provider business mailing address

1010 N KANSAS ST
WICHITA KS
67214-3124
US

V. Phone/Fax

Practice location:
  • Phone: 316-293-2635
  • Fax:
Mailing address:
  • Phone: 316-293-2635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number3-116928
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: