Provider Demographics
NPI:1760672596
Name:MANTAY, KRISTI MCCLELLAN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KRISTI
Middle Name:MCCLELLAN
Last Name:MANTAY
Suffix:
Gender:F
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 1:1380 TUSCANY DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-7751
Mailing Address - Country:US
Mailing Address - Phone:757-301-9200
Mailing Address - Fax:757-301-9214
Practice Address - Street 1:1380 TUSCANY DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-7751
Practice Address - Country:US
Practice Address - Phone:757-301-9200
Practice Address - Fax:757-301-9214
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002575363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant