Individual
MRS. MIRANDA R DETHIER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
840 W RACINE ST, JEFFERSON, WI 53549-1053
(920) 674-6000
(920) 674-3034
Mailing address
PO BOX 249, FORT ATKINSON, WI 53538-0249
(920) 568-5411
(920) 568-4004
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
2758-23
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1760770960
—
WI
Enumeration date
07/21/2011
Last updated
05/03/2017
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