Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0000X | Nurse Practitioner - Neonatal | AP5282 | AZ |
NPI | 1194167023 |
---|---|
Provider Name | Amanda Ruth Mascio |
First Address | Phoenix, AZ 85020-4492 |
Second Address | Phoenix, AZ 85020-4492 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/07/2013 |
Last Update Date | 16/10/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
861865 | (05) | AZ |