Healthcare Provider Details

I. General information

NPI: 1639477466
Provider Name (Legal Business Name): HIROKO MIURA CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3927 RUCKER AVE
EVERETT WA
98201-4833
US

IV. Provider business mailing address

PO BOX 5127
EVERETT WA
98206-5127
US

V. Phone/Fax

Practice location:
  • Phone: 425-259-0966
  • Fax:
Mailing address:
  • Phone: 425-259-0966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP60752891
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNA4031
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: