Provider Demographics
NPI:1902565682
Name:VAN DAM, MIRANDA MICHELLE (CSFA)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:MICHELLE
Last Name:VAN DAM
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3595 W SPRUCE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4217
Mailing Address - Country:US
Mailing Address - Phone:208-602-7289
Mailing Address - Fax:
Practice Address - Street 1:500 S. EAGLE RD.
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-706-8101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID205983246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID205983OtherNATIONAL BOARD OF SURGICAL TECHNOLOGY AND SURGICAL ASSISTING