Basic Information
| Provider Information | |||||||||
| NPI: | 1871950980 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANGELSDORF | ||||||||
| FirstName: | SIDNEY | ||||||||
| MiddleName: | SHANE | ||||||||
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| Credential: | AG-ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3030 N CENTRAL AVE STE 1001 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024064786 | ||||||||
| FaxNumber: | 9166364358 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W THOMAS RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024063874 | ||||||||
| FaxNumber: | 6024062335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2016 | ||||||||
| LastUpdateDate: | 08/16/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | AP8394 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LG0600X | AP8394 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.