Healthcare Provider Details

I. General information

NPI: 1760770960
Provider Name (Legal Business Name): MIRANDA R DETHIER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS MIRANDA RAE GORDY

II. Dates (important events)

Enumeration Date: 07/21/2011
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W165N5595 CREEKWOOD XING
MENOMONEE FALLS WI
53051-0685
US

IV. Provider business mailing address

470 E RED PINE CIR
DOUSMAN WI
53118-8828
US

V. Phone/Fax

Practice location:
  • Phone: 262-252-1050
  • Fax: 262-525-4781
Mailing address:
  • Phone: 608-921-8334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2758-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: