Provider Demographics
NPI:1164749693
Name:MANLEY, GARY LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LYNN
Last Name:MANLEY
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 1:3910 PECOS MCLEOD STE D100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-7445
Mailing Address - Country:US
Mailing Address - Phone:702-629-7577
Mailing Address - Fax:702-933-1490
Practice Address - Street 1:3910 PECOS MCLEOD STE D100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-7445
Practice Address - Country:US
Practice Address - Phone:702-629-7577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1209363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVDF466YMedicare PIN