Provider Demographics
NPI:1265712939
Name:DE ANDA, MAYRA C (BASCJ)
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:C
Last Name:DE ANDA
Suffix:
Gender:F
Credentials:BASCJ
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5641 MACETA AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-1213
Mailing Address - Country:US
Mailing Address - Phone:702-767-2170
Mailing Address - Fax:
Practice Address - Street 1:5641 MACETA AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-1213
Practice Address - Country:US
Practice Address - Phone:702-767-2170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner