Provider Demographics
NPI:1760868707
Name:MANGELSDORF, SHAHIDA (AGACNP)
Entity Type:Individual
Prefix:
First Name:SHAHIDA
Middle Name:
Last Name:MANGELSDORF
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:SHAHIDA
Other - Middle Name:
Other - Last Name:KHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ACNPC-AG
Mailing Address - Street 1:500 W THOMAS RD STE 500
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4220
Mailing Address - Country:US
Mailing Address - Phone:602-406-4000
Mailing Address - Fax:602-406-6498
Practice Address - Street 1:500 W THOMAS RD STE 500
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4220
Practice Address - Country:US
Practice Address - Phone:602-406-4000
Practice Address - Fax:602-406-6498
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-31
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP7695363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ056526Medicaid