Provider Demographics
NPI:1255339370
Name:BACARRA, MINNA MANALO (NP)
Entity type:Individual
Prefix:
First Name:MINNA
Middle Name:MANALO
Last Name:BACARRA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MINNA
Other - Middle Name:LYNN
Other - Last Name:MANALO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:8081 INNOVATION PARK DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4867
Practice Address - Country:US
Practice Address - Phone:571-472-1600
Practice Address - Fax:571-472-1601
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN9669632086X0206X
VA0024172064363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC017098M65Medicare PIN
P12652Medicare UPIN