Provider Demographics
NPI:1669043469
Name:MANEFFA, KEVIN JOSEPH (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOSEPH
Last Name:MANEFFA
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 1:1200 N NASH ST APT 232
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22209-3626
Mailing Address - Country:US
Mailing Address - Phone:858-888-5591
Mailing Address - Fax:
Practice Address - Street 1:6355 WALKER LN STE 401
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-3250
Practice Address - Country:US
Practice Address - Phone:703-924-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-02
Last Update Date:2022-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0008019363A00000X
VA0110-008478363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant