MEDICARE: AMANDA ROSE ELDERS PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	14379	AZ

General Provider Information

NPI Number	:	1770152423
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA ROSE ELDERS PTA

Provider Business Mailing Address
First Line	:	1239 E MCKELLIPS RD STE 112
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85203-2700
Country	:	US
Telephone Number	:	480-588-7976
Fax Number	:

Provider Business Practice Location Address
First Line	:	1239 E MCKELLIPS RD STE 112
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85203-2700
Country	:	US
Telephone Number	:	480-588-7976
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2021
Last Update Date	:	03/18/2026

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