Provider Demographics
NPI:1407273170
Name:MCMANUS, MIKAELA DIANA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MIKAELA
Middle Name:DIANA
Last Name:MCMANUS
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 1:1511 BELVIEW RD
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-8661
Mailing Address - Country:US
Mailing Address - Phone:509-220-4420
Mailing Address - Fax:
Practice Address - Street 1:BUILDING 7318 C AVE G
Practice Address - Street 2:
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459
Practice Address - Country:US
Practice Address - Phone:337-652-2988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant