Provider Demographics
NPI:1538274238
Name:FRITH, MIRANDA P (PA-C)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:P
Last Name:FRITH
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 1:1940 STONEGATE DR STE 130
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA HLS
Mailing Address - State:AL
Mailing Address - Zip Code:35242-2541
Mailing Address - Country:US
Mailing Address - Phone:205-977-9876
Mailing Address - Fax:205-977-9976
Practice Address - Street 1:1940 STONEGATE DR STE 130
Practice Address - Street 2:
Practice Address - City:VESTAVIA HLS
Practice Address - State:AL
Practice Address - Zip Code:35242
Practice Address - Country:US
Practice Address - Phone:205-977-9876
Practice Address - Fax:205-977-9976
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.346363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051048148OtherBCBS OF AL
AL51048149OtherBCBS OF AL
AL051048150OtherBCBS OF AL
AL51048150OtherBCBS OF AL
AL51048148OtherBCBS OF AL
AL510I970130OtherMEDICARE
AL051048149OtherBCBS OF AL
AL107776Medicaid
AL510-00264OtherBCBS OF AL
AL0515-54209Medicare ID - Type Unspecified
AL51048150OtherBCBS OF AL