Provider Demographics
NPI:1477801124
Name:MANTEUFFEL, DESLA REY (PA-C)
Entity Type:Individual
Prefix:
First Name:DESLA
Middle Name:REY
Last Name:MANTEUFFEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DESLA
Other - Middle Name:REY
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:901 BOREN AVE STE 1650
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3508
Practice Address - Country:US
Practice Address - Phone:206-215-6221
Practice Address - Fax:206-215-6340
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61042077363A00000X
WA61042077363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2154963Medicaid