Provider Demographics
NPI:1639108327
Name:MANCHIK, LARA A (PAC)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:A
Last Name:MANCHIK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6133 RESIDENCIA
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-9048
Mailing Address - Country:US
Mailing Address - Phone:949-706-9414
Mailing Address - Fax:
Practice Address - Street 1:27700 MEDICAL CENTER RD
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6426
Practice Address - Country:US
Practice Address - Phone:949-364-1400
Practice Address - Fax:949-365-4941
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15955363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15955Medicaid
CAWPA15955AMedicare PIN
CAP65629Medicare UPIN