Provider Demographics
NPI:1154505485
Name:MANTILLA, ERIN P (PA)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:P
Last Name:MANTILLA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:P
Other - Last Name:ROONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1250 S CEDAR CREST BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6224
Practice Address - Country:US
Practice Address - Phone:610-402-8430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-21
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053283363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical