Provider Demographics
NPI:1568427219
Name:MANANSALA, EMILE (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILE
Middle Name:
Last Name:MANANSALA
Suffix:
Gender:M
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 1:525 N 18TH ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006
Mailing Address - Country:US
Mailing Address - Phone:602-252-1510
Mailing Address - Fax:602-256-9488
Practice Address - Street 1:525 N 18TH ST
Practice Address - Street 2:SUITE 301
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006
Practice Address - Country:US
Practice Address - Phone:602-252-1510
Practice Address - Fax:602-256-9488
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2356363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ555279OtherID NUMBER
AZ555279OtherID NUMBER