Provider Demographics
NPI:1851952089
Name:MANTILLA RODRIGUEZ, ESTEBAN GUILLERMO (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:ESTEBAN
Middle Name:GUILLERMO
Last Name:MANTILLA RODRIGUEZ
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8401 CONNECTICUT AVE PH SUITE
Mailing Address - Street 2:
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-5822
Mailing Address - Country:US
Mailing Address - Phone:301-942-2212
Mailing Address - Fax:301-942-1149
Practice Address - Street 1:8401 CONNECTICUT AVE PH SUITE
Practice Address - Street 2:
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-5822
Practice Address - Country:US
Practice Address - Phone:301-942-2212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDC0007102363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant