Basic Information
| Provider Information | |||||||||
| NPI: | 1356446215 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANDUJANO | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3536 S 1100 E | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841062451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013473520 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4745 S 3200 W | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841182822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019646214 | ||||||||
| FaxNumber: | 8019829232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 11/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 6028041-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.