MEDICARE: MR. MASON SCOTT MIRANDA I

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	3-116928	KS

General Provider Information

NPI Number	:	1295699593
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MASON SCOTT MIRANDA I

Provider Business Mailing Address
First Line	:	1010 N KANSAS ST
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67214-3124
Country	:	US
Telephone Number	:	316-293-2635
Fax Number	:

Provider Business Practice Location Address
First Line	:	1010 N KANSAS ST
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67214-3124
Country	:	US
Telephone Number	:	316-293-2635
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2025
Last Update Date	:	12/11/2025

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