Provider Demographics
NPI:1043493901
Name:MTSHALI, HENRIETTA D (PA-C)
Entity Type:Individual
Prefix:
First Name:HENRIETTA
Middle Name:D
Last Name:MTSHALI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-3542
Mailing Address - Country:US
Mailing Address - Phone:215-952-1408
Mailing Address - Fax:
Practice Address - Street 1:2100 W GIRARD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-1400
Practice Address - Country:US
Practice Address - Phone:215-685-0800
Practice Address - Fax:215-865-0846
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003230L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA597586OtherMEDICARE GROUP
PACD4829OtherRR MEDICARE GROUP
PA597586OtherMEDICARE GROUP