Provider Demographics
NPI:1780787986
Name:AMBURN, MANDI GLYNN (PA-C)
Entity type:Individual
Prefix:
First Name:MANDI
Middle Name:GLYNN
Last Name:AMBURN
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 1:2200 PARK BEND DR BLDG 1
Mailing Address - Street 2:SUITE 301
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-5387
Mailing Address - Country:US
Mailing Address - Phone:125-339-0440
Mailing Address - Fax:512-339-0454
Practice Address - Street 1:2200 PARK BEND DR
Practice Address - Street 2:BUILDING 1 SUITE 301
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-5387
Practice Address - Country:US
Practice Address - Phone:512-339-0440
Practice Address - Fax:512-339-0454
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10227363A00000X
TXPA04670363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00408065OtherRAILROAD MEDICARE
TX8N9216OtherBLUE CROSS
MN517690000Medicaid
MNP00408065OtherRAILROAD MEDICARE
TX8N9216OtherBLUE CROSS
TX8L23188Medicare PIN