Basic Information
Provider Information
NPI: 1033559307
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MANDAC
FirstName: CARMEN
MiddleName: AGUILAR
NamePrefix:  
NameSuffix:  
Credential: RN, PNP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 770 WELCH RD
Address2: SUITE 100
City: PALO ALTO
State: CA
PostalCode: 943041511
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 770 WELCH RD
Address2: SUITE 100
City: PALO ALTO
State: CA
PostalCode: 943041511
CountryCode: US
TelephoneNumber: 6507258771
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/01/2013
LastUpdateDate: 09/23/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
163W00000X657489NYN Nursing Service ProvidersRegistered Nurse 
163W00000X845690CAN Nursing Service ProvidersRegistered Nurse 
363LP0200X382437NYN Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
363LP0200X95000794CAY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics

No ID Information.


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