Provider Demographics
NPI:1023461134
Name:KATTY, MIRANDA LEAH (MS PA-C)
Entity type:Individual
Prefix:MS
First Name:MIRANDA
Middle Name:LEAH
Last Name:KATTY
Suffix:
Gender:F
Credentials:MS PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:3577 W 13 MILE RD STE 202A
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6710
Practice Address - Country:US
Practice Address - Phone:248-551-0669
Practice Address - Fax:248-551-0058
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-14
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007838363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant