Provider Demographics
NPI:1619639408
Name:MCMANAMAN, TEGAN ALISSA
Entity Type:Individual
Prefix:
First Name:TEGAN
Middle Name:ALISSA
Last Name:MCMANAMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 S CLIFF AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1007
Mailing Address - Country:US
Mailing Address - Phone:605-322-2000
Mailing Address - Fax:
Practice Address - Street 1:1325 S CLIFF AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1007
Practice Address - Country:US
Practice Address - Phone:605-322-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-08
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDF09211723363LF0000X
SDCP002221363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily