Basic Information
| Provider Information | |||||||||
| NPI: | 1013159193 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUSTAPHA | ||||||||
| FirstName: | MANSURU | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | MADIGAN ARMY CENTER 9040 REID ST | ||||||||
| Address2: | ATTN: MCHJ-CLQ-C | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984311100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539682252 | ||||||||
| FaxNumber: | 2539683278 | ||||||||
| Practice Location | |||||||||
| Address1: | 9119 MIL PARK AVE | ||||||||
| Address2: | WINDER CLINIC -RAIDER CLINIC | ||||||||
| City: | JBLM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984331100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534770800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2009 | ||||||||
| LastUpdateDate: | 05/30/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.