Individual
MRS. MIRANDA R DETHIER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
W165N5595 CREEKWOOD XING, MENOMONEE FALLS, WI 53051-0685
(262) 252-1050
(262) 525-4781
Mailing address
470 E RED PINE CIR, DOUSMAN, WI 53118-8828
(608) 921-8334
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
06/23/2026
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