MEDICARE: MISS CHRISTINA DIANA MANDERBAUGH P.A.-C

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	363A00000X	Physician Assistant	MA054232	PA

General Provider Information

NPI Number	:	1861721581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS CHRISTINA DIANA MANDERBAUGH P.A.-C

Provider Business Mailing Address
First Line	:	2450 W HUNTING PARK AVE
Second Line	:	2ND FLOOR TPI
City	:	PHILADELPHIA
State	:	PA
Zip	:	19129-1302
Country	:	US
Telephone Number	:	215-926-9022
Fax Number	:	215-226-8286

Provider Business Practice Location Address
First Line	:	2118 COTTMAN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-1133
Country	:	US
Telephone Number	:	215-342-3020
Fax Number	:	215-342-3653

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

Provider Enumeration Date	:	12/08/2009
Last Update Date	:	04/24/2017

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