Provider Demographics
NPI:1245632165
Name:MANDZIARA, MICHAEL C (PA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:C
Last Name:MANDZIARA
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:509-227-7070
Practice Address - Street 1:9631 N NEVADA ST STE 300
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-1193
Practice Address - Country:US
Practice Address - Phone:509-465-3919
Practice Address - Fax:509-227-7070
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2024-03-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAPA61256932363A00000X
MI5601007182363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant