Healthcare Provider Details

I. General information

NPI: 1487769386
Provider Name (Legal Business Name): TRICIA MANALASTAS P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2888 LONG BEACH BLVD. SUITE 180
LONG BEACH CA
90807
US

IV. Provider business mailing address

23560 CRENSHAW BLVD. SUITE 102
TORRANCE CA
90505-1530
US

V. Phone/Fax

Practice location:
  • Phone: 562-595-5424
  • Fax:
Mailing address:
  • Phone: 310-784-2355
  • Fax: 310-517-1817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA15922
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: