Provider Demographics
NPI:1265410120
Name:MANALO, EDNA M (PA)
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:M
Last Name:MANALO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3516
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:2516 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1608
Practice Address - Country:US
Practice Address - Phone:260-471-7197
Practice Address - Fax:260-471-7408
Is Sole Proprietor?:No
Enumeration Date:2006-01-02
Last Update Date:2020-10-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN10000418A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100326320Medicaid
INP01146780OtherRAILROAD MEDICARE
INP01146780OtherRAILROAD MEDICARE
P17002Medicare UPIN
INM400048072Medicare PIN