Healthcare Provider Details

I. General information

NPI: 1538811138
Provider Name (Legal Business Name): MIRANDA JO RISTAU OBANIANA DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2022
Last Update Date: 11/25/2022
Certification Date: 11/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 SAINT OLAF AVE S
CANBY MN
56220-1433
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 507-223-7277
  • Fax:
Mailing address:
  • Phone: 605-328-6585
  • Fax: 605-312-9802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2321
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12331
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: