Provider Demographics
NPI:1538965256
Name:BASTO, MIRANDA (PAC)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:BASTO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 RIVERSIDE PKWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5925
Mailing Address - Country:US
Mailing Address - Phone:770-237-3475
Mailing Address - Fax:770-237-3756
Practice Address - Street 1:1900 RIVERSIDE PKWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5925
Practice Address - Country:US
Practice Address - Phone:770-237-3475
Practice Address - Fax:770-237-3756
Is Sole Proprietor?:No
Enumeration Date:2025-02-22
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA13251363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant