Provider Demographics
NPI:1871668152
Name:UMANZOR, MANUEL ERNESTO (PA)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:ERNESTO
Last Name:UMANZOR
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7444 LANKERSHIM BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91605-2801
Mailing Address - Country:US
Mailing Address - Phone:818-765-4917
Mailing Address - Fax:818-765-0804
Practice Address - Street 1:7444 LANKERSHIM BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91605-2801
Practice Address - Country:US
Practice Address - Phone:818-765-4917
Practice Address - Fax:818-765-0804
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13435363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR95669Medicare UPIN