Provider Demographics
NPI:1720385719
Name:MANRIQUE, PATRICK G (DPT)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:G
Last Name:MANRIQUE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BROOKE ARMY MEDICAL CENTER (BAMC)
Mailing Address - Street 2:3551 ROGER BROOKE DR
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-808-6669
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:JBSA FT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-808-6669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070018334225100000X
IN05010787A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216860049Medicare PIN
IL216859181Medicare PIN