Basic Information
| Provider Information | |||||||||
| NPI: | 1578731147 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMDE-MICHAEL | ||||||||
| FirstName: | TIZITA | ||||||||
| MiddleName: | |||||||||
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| Credential: | CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 ST PAUL AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900172038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2134826400 | ||||||||
| FaxNumber: | 2134826408 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 ST PAUL AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900172038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2134826400 | ||||||||
| FaxNumber: | 2134826408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2008 | ||||||||
| LastUpdateDate: | 01/08/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 17768 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | 661686 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | 4436 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363L00000X | 17768 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1578731147 | 05 | WI | MEDICAID | 100500484 | 05 | CA | MEDICAID | 100500484 GROUP | 05 | NV | MEDICAID |