MEDICARE: MARIA SOCORRO MIRANDA GANDARA FNP

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	163W00000X	Registered Nurse	RN60231010	WA
2	363L00000X	Nurse Practitioner	AP60909533	WA
3	363LF0000X	Family Nurse Practitioner	AP60909533	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366625717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA SOCORRO MIRANDA GANDARA FNP

Provider Business Mailing Address
First Line	:	CAPITAL EASTSIDE FAMILY PRACTICE
Second Line	:	1100 EASTSIDE ST SE
City	:	OLYMPIA
State	:	WA
Zip	:	98501
Country	:	US
Telephone Number	:	360-943-5127
Fax Number	:	360-754-2516

Provider Business Practice Location Address
First Line	:	1100 EASTSIDE ST SE
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98501-7304
Country	:	US
Telephone Number	:	360-943-5127
Fax Number	:	360-754-2516

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

Provider Enumeration Date	:	12/07/2007
Last Update Date	:	10/10/2023

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