Provider Demographics
NPI:1164915203
Name:MANZELLA, SALVATORE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SALVATORE
Middle Name:
Last Name:MANZELLA
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 1:8408 ADLER CT
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-1771
Mailing Address - Country:US
Mailing Address - Phone:202-373-5840
Mailing Address - Fax:412-729-5060
Practice Address - Street 1:1800 ORLEANS ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0010
Practice Address - Country:US
Practice Address - Phone:410-955-6146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC06998363A00000X
VA0110006469363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant