Provider Demographics
NPI:1730292244
Name:MANZO, MARY MOON (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MOON
Last Name:MANZO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 DUDLEY ST
Mailing Address - Street 2:STE 200
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-3248
Mailing Address - Country:US
Mailing Address - Phone:401-849-6868
Mailing Address - Fax:401-847-3840
Practice Address - Street 1:19 FRIENDSHIP ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-2272
Practice Address - Country:US
Practice Address - Phone:401-849-6868
Practice Address - Fax:401-847-3840
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA 449363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPA 449OtherRI LICENSE
RI414659OtherBLUE CHIP
RI33279OtherBS
RIP83861Medicare UPIN