Healthcare Provider Details

I. General information

NPI: 1083108831
Provider Name (Legal Business Name): SUZANNE J MIRON NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2018
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 S 7TH ST
ONTONAGON MI
49953
US

IV. Provider business mailing address

301 EXPLORER ST
GWINN MI
49841-2813
US

V. Phone/Fax

Practice location:
  • Phone: 906-884-4120
  • Fax:
Mailing address:
  • Phone: 906-346-4924
  • Fax: 906-346-6474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704201024
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number4704201024
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: