Provider Demographics
NPI:1760858534
Name:MANNY, TARA (PA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:MANNY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:25 WILLOWBROOK RD STE 2
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-3137
Mailing Address - Country:US
Mailing Address - Phone:518-793-9156
Mailing Address - Fax:518-793-6591
Practice Address - Street 1:25 WILLOWBROOK RD STE 2
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-3137
Practice Address - Country:US
Practice Address - Phone:518-793-9156
Practice Address - Fax:518-793-6591
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY018734363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04351997Medicaid