Provider Demographics
NPI:1881970234
Name:MIRO, STEPHEN J (PA)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:J
Last Name:MIRO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 JEFFERSON STREET
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767
Mailing Address - Country:US
Mailing Address - Phone:631-428-3923
Mailing Address - Fax:
Practice Address - Street 1:694 MOTOR PARKWAY
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788
Practice Address - Country:US
Practice Address - Phone:631-265-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-31
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015314363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical