Provider Demographics
NPI:1104876101
Name:MANKINS, GORDON S (PA-C)
Entity type:Individual
Prefix:MR
First Name:GORDON
Middle Name:S
Last Name:MANKINS
Suffix:
Gender:M
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:P.O. BOX 29870
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-9870
Mailing Address - Country:US
Mailing Address - Phone:602-772-3805
Mailing Address - Fax:602-772-3801
Practice Address - Street 1:5620 E BELL RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-5950
Practice Address - Country:US
Practice Address - Phone:602-493-9361
Practice Address - Fax:602-493-9508
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ252363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
3Z3914OtherHEALTHNET ID
AZ494097Medicaid
AZP00842018Medicare PIN
AZ494097Medicaid