Provider Demographics
NPI:1093792756
Name:MANIGO-HEDT, STEPHEN M (PA-C)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:M
Last Name:MANIGO-HEDT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 1ST AVE
Mailing Address - Street 2:APT 1304
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2149
Mailing Address - Country:US
Mailing Address - Phone:206-290-0612
Mailing Address - Fax:
Practice Address - Street 1:201 SOUTH B STREET
Practice Address - Street 2:CAMARENA HEALTH CENTER
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93638
Practice Address - Country:US
Practice Address - Phone:559-664-4004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101826363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2754244AMedicare ID - Type Unspecified
NCP94569Medicare UPIN