Provider Demographics
NPI:1407491707
Name:MANZANO, DARREN
Entity Type:Individual
Prefix:
First Name:DARREN
Middle Name:
Last Name:MANZANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 S GRAND AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-3075
Mailing Address - Country:US
Mailing Address - Phone:213-675-8088
Mailing Address - Fax:
Practice Address - Street 1:1513 S GRAND AVE STE 208
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3075
Practice Address - Country:US
Practice Address - Phone:213-675-8088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-10
Last Update Date:2020-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant