| Organization Name: | MIRANDA MCCORMACK, M.D., LLC |
| NPI Number: | 1043488166 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MIRANDA CHRISTIE MCCORMACK (PHYSICIAN/OWNER) |
| Mailing Address: | 5040 Sw Griffith Dr #201 Beaverton |
| State: | OR US |
| Postal Code: | 970052985 |
| Phone Number: | 5036162224 |
| Fax Number: | |
| NPI Enumeration Date: | 02/11/2008 |
| NPI Last Update Date: | 02/11/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2300X |
| License Number: | 465592-90 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OR |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Primary Care |
| Taxonomy Definition: | |