Provider Demographics
NPI:1649837279
Name:DIONGO, PATRICK MANZANZA
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:MANZANZA
Last Name:DIONGO
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 1:345 SACO ST UNIT 9
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04092-2067
Mailing Address - Country:US
Mailing Address - Phone:646-662-2619
Mailing Address - Fax:
Practice Address - Street 1:345 SACO ST UNIT 9
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-2067
Practice Address - Country:US
Practice Address - Phone:646-662-2619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME00009171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME83-4495838Medicaid