1790221786 NPI number — MIRANDA POMIJE ATC, LAT

Table of content: MIRANDA POMIJE ATC, LAT (NPI 1790221786)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790221786 NPI number — MIRANDA POMIJE ATC, LAT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POMIJE
Provider First Name:
MIRANDA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ATC, LAT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790221786
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1614 PARKER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDAR FALLS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50613-4627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-594-1104
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2351 HUDSON ROAD
Provider Second Line Business Practice Location Address:
UNIVERSITY OF NORTHERN IOWA- ATHLETIC TRAINING
Provider Business Practice Location Address City Name:
CEDAR FALLS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-273-2311
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/13/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  078761 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)