MEDICARE: MANZANITA MEDICAL PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician		AZ

General Provider Information

NPI Number	:	1306376611
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MANZANITA MEDICAL PLLC

Provider Business Mailing Address
First Line	:	4545 E SHEA BLVD STE 130
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85028-3061
Country	:	US
Telephone Number	:	480-292-9532
Fax Number	:	480-664-3482

Provider Business Practice Location Address
First Line	:	4545 E SHEA BLVD STE 130
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85028-3061
Country	:	US
Telephone Number	:	480-292-9532
Fax Number	:	480-664-3482

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	JUDITH HALLAS
Credential	:
Telephone Number	:	480-292-9532

Provider Enumeration Date	:	06/19/2017
Last Update Date	:	07/23/2024

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