Provider Demographics
NPI:1841003787
Name:MANNER, DESTINY ASTIN
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:ASTIN
Last Name:MANNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3959 STADIUM WAY DEPT 3913
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84408-0001
Mailing Address - Country:US
Mailing Address - Phone:801-921-3289
Mailing Address - Fax:
Practice Address - Street 1:3959 STADIUM WAY DEPT 3913
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84408-0001
Practice Address - Country:US
Practice Address - Phone:801-921-3289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant