Provider Demographics
NPI:1164202289
Name:MANACOV, TATIANA (PA-C)
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:MANACOV
Suffix:
Gender:F
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 1:1308 MARGATE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-2156
Mailing Address - Country:US
Mailing Address - Phone:810-471-8679
Mailing Address - Fax:
Practice Address - Street 1:218 STRATHY LN
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-4133
Practice Address - Country:US
Practice Address - Phone:407-628-3073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-05
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL363AM0700X
FLPA9118076363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical