Provider Demographics
NPI:1245485846
Name:MIRACLE, GRETA LOUISE (PA-C)
Entity type:Individual
Prefix:
First Name:GRETA
Middle Name:LOUISE
Last Name:MIRACLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 NE 80TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-7019
Mailing Address - Country:US
Mailing Address - Phone:206-313-1113
Mailing Address - Fax:
Practice Address - Street 1:16703 SE MCGILLIVRAY BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4300
Practice Address - Country:US
Practice Address - Phone:360-566-4840
Practice Address - Fax:360-566-4841
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60058267363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant