Provider Demographics
NPI:1316040660
Name:MANZANARES, KATHERINE JANE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:JANE
Last Name:MANZANARES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224-D CORNWALL STREET, NW, SUITE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:
Practice Address - Street 1:1800 NORTH BEAUREGARD STREET, SUITE 250
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-5879
Practice Address - Country:US
Practice Address - Phone:703-370-2400
Practice Address - Fax:703-370-7214
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA030510363AS0400X
VA0110003633363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1316040660Medicaid
VA30017449730003Medicaid