Provider Demographics
NPI:1760197958
Name:MANER, EDWARD MATTHEW (PA-C)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:MATTHEW
Last Name:MANER
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 1:330 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:MS
Mailing Address - Zip Code:39074-3508
Mailing Address - Country:US
Mailing Address - Phone:601-469-4151
Mailing Address - Fax:
Practice Address - Street 1:330 N BROAD ST
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:MS
Practice Address - Zip Code:39074-3508
Practice Address - Country:US
Practice Address - Phone:601-469-4151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1020521146N00000X
MS363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic