Provider Demographics
NPI:1922216233
Name:TABANDA-LICHAUCO, ROSA TRINIDAD C (MD)
Entity Type:Individual
Prefix:DR
First Name:ROSA TRINIDAD
Middle Name:C
Last Name:TABANDA-LICHAUCO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ROSA TRINIDAD
Other - Middle Name:C
Other - Last Name:TABANDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:HEREFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85615-0609
Mailing Address - Country:US
Mailing Address - Phone:520-335-1800
Mailing Address - Fax:520-335-2743
Practice Address - Street 1:300 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2812
Practice Address - Country:US
Practice Address - Phone:520-335-1800
Practice Address - Fax:520-335-2743
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36678174400000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ824163Medicaid
AZZ164292Medicare PIN