Healthcare Provider Details

I. General information

NPI: 1770152423
Provider Name (Legal Business Name): AMANDA ROSE ELDERS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA ROSE JANS

II. Dates (important events)

Enumeration Date: 06/17/2021
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1239 E MCKELLIPS RD STE 112
MESA AZ
85203-2700
US

IV. Provider business mailing address

1239 E MCKELLIPS RD STE 112
MESA AZ
85203-2700
US

V. Phone/Fax

Practice location:
  • Phone: 480-588-7976
  • Fax:
Mailing address:
  • Phone: 480-588-7976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number14379
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: