Provider Demographics
NPI:1902835606
Name:MANCHENTON, KEVIN P (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:P
Last Name:MANCHENTON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12730
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85732-2730
Mailing Address - Country:US
Mailing Address - Phone:520-647-8850
Mailing Address - Fax:520-647-8851
Practice Address - Street 1:1601 W SAINT MARYS RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-2623
Practice Address - Country:US
Practice Address - Phone:520-872-4901
Practice Address - Fax:520-901-3642
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ2349363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP91155Medicare UPIN
AZZ75219Medicare PIN
AZZ105834Medicare PIN