Provider Demographics
NPI:1003048901
Name:MANIGO, LAURA (PA-C, MMS)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MANIGO
Suffix:
Gender:F
Credentials:PA-C, MMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8150 N 61ST AVE APT 1021
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-6757
Mailing Address - Country:US
Mailing Address - Phone:206-290-7684
Mailing Address - Fax:
Practice Address - Street 1:13090 N 94TH DR STE 202
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4258
Practice Address - Country:US
Practice Address - Phone:206-290-7684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA 10004828363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCS66283Medicare UPIN