Provider Demographics
NPI:1588010326
Name:MANSON, JACK (PA)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:MANSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11239 VENTURA BLVD
Mailing Address - Street 2:213
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-3163
Mailing Address - Country:US
Mailing Address - Phone:760-936-7189
Mailing Address - Fax:
Practice Address - Street 1:11239 VENTURA BLVD
Practice Address - Street 2:213
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-3163
Practice Address - Country:US
Practice Address - Phone:760-936-7189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23246363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant