Provider Demographics
NPI:1356446215
Name:MANDUJANO, MARTHA P (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:P
Last Name:MANDUJANO
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 1:3536 S 1100 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2451
Mailing Address - Country:US
Mailing Address - Phone:801-347-3520
Mailing Address - Fax:
Practice Address - Street 1:4745 S 3200 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84118-2822
Practice Address - Country:US
Practice Address - Phone:801-964-6214
Practice Address - Fax:801-982-9232
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2021-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6028041-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTQ68154Medicare UPIN