Provider Demographics
NPI:1558648550
Name:MANALANG, SHANE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:MANALANG
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 TERMINO AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-2126
Mailing Address - Country:US
Mailing Address - Phone:310-552-0146
Mailing Address - Fax:310-552-0185
Practice Address - Street 1:3625 MARTIN LUTHER KING JR BLVD STE 5
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3509
Practice Address - Country:US
Practice Address - Phone:562-508-8787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-04
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21395363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty