Basic Information
| Provider Information | |||||||||
| NPI: | 1982865739 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANDRELLE | ||||||||
| FirstName: | RAMNISH | ||||||||
| MiddleName: | JAGDISH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MBBS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 451 SW SEDGWICK RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | PORT ORCHARD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983676447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608745900 | ||||||||
| FaxNumber: | 3608745959 | ||||||||
| Practice Location | |||||||||
| Address1: | 451 SW SEDGWICK RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | PORT ORCHARD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983676447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608745900 | ||||||||
| FaxNumber: | 3608745959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2008 | ||||||||
| LastUpdateDate: | 04/06/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD60063868 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0252141 | 01 | WA | STATE L&I | OTHER |