Miranda Debord Willette, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

PA07761 Issued in TX

Practice address

2710 Nogalitos
San Antonio, TX 78225-1750

Phone

(210) 436-8400

Fax

(833) 452-1052

NPI assigned

Mar 23, 2012

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 3

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in TX

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Joseph a Marotta MD PA

  • Internal Medicine Physician
  • San Antonio, TX
  • NPI 1669634192
  Medicare reassignment
• Riverwalk Clinic, LLC

  • Urgent Care Clinic/Center
  • San Antonio, TX
  • NPI 1629191176
  NPD (past)
• Zarate Medical Group PA

  • Internal Medicine Physician
  • San Antonio, TX
  • NPI 1285761809
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1332460800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1678147200000",
    "number": "1578839593",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2710 NOGALITOS STE 104",
            "city": "SAN ANTONIO",
            "state": "TX",
            "postal_code": "782251750",
            "telephone_number": "210-436-8400",
            "fax_number": "833-452-1052"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2710 NOGALITOS",
            "city": "SAN ANTONIO",
            "state": "TX",
            "postal_code": "782251750",
            "telephone_number": "210-436-8400",
            "fax_number": "833-452-1052"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "12702 Toepperwein",
            "address_2": "Suite 104",
            "address_purpose": "LOCATION",
            "city": "San Antonio",
            "state": "TX",
            "postal_code": "78233",
            "country_code": "US",
            "telephone_number": "210-653-4420",
            "fax_number": "210-653-3183",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WILLETTE",
        "first_name": "MIRANDA",
        "middle_name": "DEBORD",
        "name_prefix": "Mrs.",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2012-03-23",
        "last_updated": "2023-03-07",
        "certification_date": "2023-01-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "TX",
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "TX",
            "license": "PA07761",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DPS",
            "identifier": "R0187954",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICAL LICENSE",
            "identifier": "PA07761",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CAQH",
            "identifier": "12370726",
            "state": "TX"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "miranda.willette.1@13711.direct.athenahealth.com",
            "affiliation": "N",
            "endpointDescription": "Village Medical Texas",
            "address_1": "2710 Nogalitos",
            "city": "San Antonio",
            "state": "TX",
            "country_code": "US",
            "postal_code": "782251750",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Dena Lynnette Willeford, LPC
• Brooklynn Willert
• Amanda Willett, RN
• Ryan Willett
• Wren Willett
• Donna B Willey-Courand, MD
• Mica Willey, RBT
• Lourdes Alejandra Willhite, DDS
• William a Atlas MD PA
• William a. Tisdall, M.D., P.a.

• Physician Assistant in San Antonio, TX
• Providers in San Antonio, TX by specialty
• Physician Assistant in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 7, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.