Provider Demographics
NPI:1578731147
Name:AMDE-MICHAEL, TIZITA (CPNP)
Entity Type:Individual
Prefix:
First Name:TIZITA
Middle Name:
Last Name:AMDE-MICHAEL
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 ST PAUL AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-2038
Mailing Address - Country:US
Mailing Address - Phone:213-482-6400
Mailing Address - Fax:213-482-6408
Practice Address - Street 1:600 ST PAUL AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-2038
Practice Address - Country:US
Practice Address - Phone:213-482-6400
Practice Address - Fax:213-482-6408
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17768363LP0200X, 363L00000X
CA661686363LP0200X
WI4436363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1578731147Medicaid
CA100500484Medicaid
NV100500484 GROUPMedicaid
CAWQBHVMedicare PIN
CA100500484Medicaid