MEDICARE: MIRANDA NELSON PT, DPT

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1710686357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRANDA NELSON PT, DPT

Provider Business Mailing Address
First Line	:	625 KENMOOR AVE SE STE 100
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-2395
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4242 HONDO PASS DR STE 110
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79904-1211
Country	:	US
Telephone Number	:	915-751-0599
Fax Number	:

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

Provider Enumeration Date	:	03/02/2023
Last Update Date	:	03/02/2023

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