Healthcare Provider Details

I. General information

NPI: 1003857830
Provider Name (Legal Business Name): MIRANDA C JOHNSTON P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 01/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

281 W 4TH ST
INDEPENDENCE LA
70443-2386
US

IV. Provider business mailing address

2057 WHITE MYRTLE DR
MADISONVILLE LA
70447-9480
US

V. Phone/Fax

Practice location:
  • Phone: 985-878-0066
  • Fax: 985-878-0626
Mailing address:
  • Phone: 985-259-0822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.A10528.RX
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: