Provider Demographics
NPI:1144611971
Name:MARKESTEYN, MIRANDA LEE (PA)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LEE
Last Name:MARKESTEYN
Suffix:
Gender:F
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:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2006 HEALTH CAMPUS DR FL 2
Practice Address - Street 2:
Practice Address - City:ROCKINGHAM
Practice Address - State:VA
Practice Address - Zip Code:22801-8679
Practice Address - Country:US
Practice Address - Phone:540-689-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-16
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60613313363A00000X
ORPA201988363AS0400X
FLPA9108211363AS0400X
VA0110006164363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP01576017OtherRR PTAN
WA1144611971Medicaid
WAP01576017OtherRR PTAN