Healthcare Provider Details

I. General information

NPI: 1609152479
Provider Name (Legal Business Name): MANDIE MILLER DMS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA ANDERSON MMS, PA-C

II. Dates (important events)

Enumeration Date: 10/25/2011
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17505 N 79TH AVE STE 309
GLENDALE AZ
85308-8730
US

IV. Provider business mailing address

17505 N 79TH AVE STE 309
GLENDALE AZ
85308-8730
US

V. Phone/Fax

Practice location:
  • Phone: 623-321-2221
  • Fax: 855-397-2676
Mailing address:
  • Phone: 623-321-2221
  • Fax: 855-397-2676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4918
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4918
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: