Provider Demographics
NPI:1659430254
Name:MCMANAMA, CRAIG ALAN (DPM)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:ALAN
Last Name:MCMANAMA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3540 S 4000 W STE 480
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-3285
Mailing Address - Country:US
Mailing Address - Phone:801-966-3556
Mailing Address - Fax:801-966-9839
Practice Address - Street 1:3540 S 4000 W STE 480
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-3285
Practice Address - Country:US
Practice Address - Phone:801-966-3556
Practice Address - Fax:801-966-9839
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT781028940501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T77936Medicare UPIN
000001465Medicare ID - Type Unspecified