Provider Demographics
NPI:1184771677
Name:MANTUA, ALISON BETH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ALISON
Middle Name:BETH
Last Name:MANTUA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:ALISON
Other - Middle Name:BETH
Other - Last Name:GOLDFARB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8503 ARLINGTON BLVD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4628
Mailing Address - Country:US
Mailing Address - Phone:703-208-4200
Mailing Address - Fax:703-876-1799
Practice Address - Street 1:8503 ARLINGTON BLVD
Practice Address - Street 2:SUITE 310
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4628
Practice Address - Country:US
Practice Address - Phone:703-208-4200
Practice Address - Fax:703-876-1799
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001075363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP01510Medicare UPIN