Provider Demographics
NPI:1740553056
Name:MANNEH, ALEXIS MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:MARIE
Last Name:MANNEH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5741 W CROWLEY AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-5146
Mailing Address - Country:US
Mailing Address - Phone:818-317-8165
Mailing Address - Fax:
Practice Address - Street 1:2100 POWELL ST STE 900
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-1844
Practice Address - Country:US
Practice Address - Phone:510-350-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21689363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant