Basic Information
| Provider Information | |||||||||
| NPI: | 1043639255 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANDELMAN | ||||||||
| FirstName: | TINA | ||||||||
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| Credential: | APN CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3003 N CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023233344 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 N 48TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850085803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022437277 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2014 | ||||||||
| LastUpdateDate: | 07/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 274213 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | 209.011209 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.