Provider Demographics
NPI:1669584736
Name:MERRYMAN, MIRAMANNEE L (PA)
Entity type:Individual
Prefix:
First Name:MIRAMANNEE
Middle Name:L
Last Name:MERRYMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MIRAMANNEE
Other - Middle Name:M
Other - Last Name:LENZINI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 1138
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-1138
Mailing Address - Country:US
Mailing Address - Phone:310-582-7084
Mailing Address - Fax:
Practice Address - Street 1:2001 SANTA MONICA BLVD STE 680W
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2111
Practice Address - Country:US
Practice Address - Phone:310-829-8928
Practice Address - Fax:310-315-6157
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17368363AM0700X
CA17368363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S90742Medicare UPIN
CAWPA17368AMedicare ID - Type Unspecified
CABQ883ZMedicare PIN