Healthcare Provider Details

I. General information

NPI: 1245632165
Provider Name (Legal Business Name): MICHAEL C. MANDZIARA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9631 N NEVADA ST STE 300
SPOKANE WA
99218-1193
US

IV. Provider business mailing address

PO BOX 421
LIBERTY LAKE WA
99019-0421
US

V. Phone/Fax

Practice location:
  • Phone: 509-465-3919
  • Fax: 509-227-7070
Mailing address:
  • Phone: 866-747-2455
  • Fax: 509-227-7070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61256932
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601007182
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: