Provider Demographics
NPI:1013159193
Name:MUSTAPHA, MANSURU (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:MANSURU
Middle Name:
Last Name:MUSTAPHA
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:MADIGAN ARMY CENTER 9040 REID ST
Mailing Address - Street 2:ATTN: MCHJ-CLQ-C
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-1100
Mailing Address - Country:US
Mailing Address - Phone:253-968-2252
Mailing Address - Fax:253-968-3278
Practice Address - Street 1:9119 MIL PARK AVE
Practice Address - Street 2:WINDER CLINIC -RAIDER CLINIC
Practice Address - City:JBLM
Practice Address - State:WA
Practice Address - Zip Code:98433-1100
Practice Address - Country:US
Practice Address - Phone:253-477-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-03
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN