Provider Demographics
NPI:1164837126
Name:MANKE, NICHOLAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:
Last Name:MANKE
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 1:550 GAGE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 GOETHALS DR
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3300
Practice Address - Country:US
Practice Address - Phone:509-946-4611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2014-0037363AM0700X
WAPA60820907363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical