Provider Demographics
NPI:1932673209
Name:MANCHEGO, JOSE MANUEL
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MANUEL
Last Name:MANCHEGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16801 NW 67TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-4203
Mailing Address - Country:US
Mailing Address - Phone:305-362-8255
Mailing Address - Fax:
Practice Address - Street 1:16801 NW 67TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-4203
Practice Address - Country:US
Practice Address - Phone:305-362-8255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11000250363LF0000X
FLAPRN11000250363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily