Provider Demographics
NPI:1801150511
Name:MANN, ANTHONY ROBERT (PA-C)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:ROBERT
Last Name:MANN
Suffix:
Gender:M
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 1:16909 LAKESIDE HILLS CT
Mailing Address - Street 2:SUITE 208
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-4664
Mailing Address - Country:US
Mailing Address - Phone:402-758-5690
Mailing Address - Fax:
Practice Address - Street 1:16909 LAKESIDE HILLS CT
Practice Address - Street 2:SUITE 208
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-4664
Practice Address - Country:US
Practice Address - Phone:402-758-5690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1665363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical