Healthcare Provider Details

I. General information

NPI: 1033672753
Provider Name (Legal Business Name): MINKEALE TEDLA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14419 W MCDOWELL RD
GOODYEAR AZ
85395-2511
US

IV. Provider business mailing address

14419 W MCDOWELL RD
GOODYEAR AZ
85395-2511
US

V. Phone/Fax

Practice location:
  • Phone: 623-248-1950
  • Fax:
Mailing address:
  • Phone: 623-248-1950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: