Provider Demographics
NPI:1538181599
Name:MANSELL, PASCAL DOMINIQUE
Entity type:Individual
Prefix:MR
First Name:PASCAL
Middle Name:DOMINIQUE
Last Name:MANSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 32
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92556-0032
Mailing Address - Country:US
Mailing Address - Phone:602-264-4770
Mailing Address - Fax:602-264-4771
Practice Address - Street 1:2302 N 15TH AVE
Practice Address - Street 2:111
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-1201
Practice Address - Country:US
Practice Address - Phone:602-264-4770
Practice Address - Fax:602-264-4771
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ07681098332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4646400002Medicare UPIN