Provider Demographics
NPI:1669940896
Name:XI, MANDY (PA-C)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:XI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 SEAVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3436
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:475 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3436
Practice Address - Country:US
Practice Address - Phone:718-226-9250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022968363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY022968OtherNYS LICENSING DEPARTMENT FOR PA-C
NY1157035OtherNCCPA
NY440014956OtherNYS LEARNER PERMIT