Provider Demographics
NPI:1972691384
Name:ROBINSON, MANDA BETH (PAC)
Entity type:Individual
Prefix:MRS
First Name:MANDA
Middle Name:BETH
Last Name:ROBINSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MISS
Other - First Name:MANDA
Other - Middle Name:BETH
Other - Last Name:TEETER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:625 N ALAMEDA AVE
Mailing Address - Street 2:B
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702
Mailing Address - Country:US
Mailing Address - Phone:909-525-8156
Mailing Address - Fax:
Practice Address - Street 1:311 E WINSTON STREET
Practice Address - Street 2:LOS ANGELES MISSION COMMUNITY CLINIC
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013
Practice Address - Country:US
Practice Address - Phone:213-893-1960
Practice Address - Fax:213-893-1960
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18522363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM70948FMedicaid
CAEA970948FOtherEAPC
CACMM70948FMedicaid