Provider Demographics
NPI:1437290038
Name:MANNING, KATHLEEN (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MANNING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 S MAIN ST
Mailing Address - Street 2:MOB 2 THIRD FLOOR
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-5318
Mailing Address - Country:US
Mailing Address - Phone:925-295-4110
Mailing Address - Fax:925-295-7234
Practice Address - Street 1:1425 S MAIN ST
Practice Address - Street 2:MOB 2 THIRD FLOOR
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-5318
Practice Address - Country:US
Practice Address - Phone:925-295-4110
Practice Address - Fax:925-295-7234
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044301208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8412041Medicaid
WAG8859727Medicare ID - Type Unspecified
WA8412041Medicaid