Provider Demographics
NPI:1003042441
Name:MANZO, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MANZO
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 1:210 PARK AVE STE 163
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-2246
Mailing Address - Country:US
Mailing Address - Phone:508-752-0843
Mailing Address - Fax:
Practice Address - Street 1:210 PARK AVE STE 163
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-2246
Practice Address - Country:US
Practice Address - Phone:508-752-0843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-29
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA3715363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9773312Medicaid
MA9773312Medicaid