Provider Demographics
NPI:1871826040
Name:MIRANDA, ADRIAN G (BMS)
Entity type:Individual
Prefix:
First Name:ADRIAN
Middle Name:G
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:BMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 W. 21ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101
Mailing Address - Country:US
Mailing Address - Phone:575-769-2345
Mailing Address - Fax:575-769-9013
Practice Address - Street 1:300 EAST FIRST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130
Practice Address - Country:US
Practice Address - Phone:575-359-1221
Practice Address - Fax:575-359-1075
Is Sole Proprietor?:No
Enumeration Date:2009-09-04
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator