Provider Demographics
NPI:1679627855
Name:BROOKSHIRE, MIRANDA PREWITT (PA)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:PREWITT
Last Name:BROOKSHIRE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 BOONESBORO RD
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-8816
Mailing Address - Country:US
Mailing Address - Phone:859-744-0067
Mailing Address - Fax:859-744-0042
Practice Address - Street 1:29 CANARY LN
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-1645
Practice Address - Country:US
Practice Address - Phone:859-745-4469
Practice Address - Fax:859-745-6918
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2016-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA495363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95005765Medicaid
KY95005765Medicaid