Provider Demographics
NPI:1912971862
Name:MANVILLE, ALBERT J (PA)
Entity Type:Individual
Prefix:MR
First Name:ALBERT
Middle Name:J
Last Name:MANVILLE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2331 FRANKLIN RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-1111
Mailing Address - Country:US
Mailing Address - Phone:540-725-1226
Mailing Address - Fax:540-857-5306
Practice Address - Street 1:2331 FRANKLIN RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1111
Practice Address - Country:US
Practice Address - Phone:540-725-1226
Practice Address - Fax:540-857-5306
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-001242363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1912971862OtherMEDICAID QMB
VA1912971862OtherANTHEM MEDIGAP
VA1912971862OtherOPTIMA HEALTH PLAN
VAP00191374OtherRAILROAD MEDICARE
VA1912971862OtherSOUTHERN HEALTH/CARENET/CARELINK/COVENTRY
VA1912971862OtherAETNA
VA371194700OtherBLACK LUNG
VA1912971862OtherHUMANA MEDICARE
VA1912971862OtherINTOTAL
VA1912971862OtherUMWA
VA540506332108OtherTRICARE/CHAMPUS
VA1912971862OtherCCC VIRGINIA PREMIER
VA1912971862OtherSOUTHERN HEALTH/CARENET/CARELINK/COVENTRY
VA1912971862OtherCCC VIRGINIA PREMIER