Healthcare Provider Details

I. General information

NPI: 1639108327
Provider Name (Legal Business Name): LARA A MANCHIK P.A.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 02/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27700 MEDICAL CENTER RD
MISSION VIEJO CA
92691-6426
US

IV. Provider business mailing address

6133 RESIDENCIA
NEWPORT BEACH CA
92660-9048
US

V. Phone/Fax

Practice location:
  • Phone: 949-364-1400
  • Fax: 949-365-4941
Mailing address:
  • Phone: 949-706-9414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA15955
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: