Provider Demographics
NPI:1932285541
Name:MANDRELL, RONALD P (PA)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:P
Last Name:MANDRELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 255228
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-5228
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:1234 EMPIRE ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-5711
Practice Address - Country:US
Practice Address - Phone:707-426-3911
Practice Address - Fax:707-434-2029
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06795363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA13843Medicaid
CAPA13843Medicaid
P81444Medicare UPIN