Provider Demographics
NPI:1982056719
Name:MANAK, ERIN (PA-C)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:MANAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:
Other - Last Name:EVENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2101 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-1406
Mailing Address - Country:US
Mailing Address - Phone:720-745-8030
Mailing Address - Fax:720-745-8031
Practice Address - Street 1:2101 MAIN ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-1406
Practice Address - Country:US
Practice Address - Phone:720-745-8030
Practice Address - Fax:720-745-8031
Is Sole Proprietor?:No
Enumeration Date:2016-07-05
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
COPA.0004690363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO21175071Medicaid