Healthcare Provider Details

I. General information

NPI: 1285663112
Provider Name (Legal Business Name): SARAH MANALANSAN MANNEH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARAH WILSON

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 BOTTINEAU BLVD #210
CRYSTAL MN
55429-3183
US

IV. Provider business mailing address

5700 BOTTINEAU BLVD #210
CRYSTAL MN
55429-3183
US

V. Phone/Fax

Practice location:
  • Phone: 763-587-7000
  • Fax: 763-587-7015
Mailing address:
  • Phone: 763-587-7000
  • Fax: 763-587-7015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number45050
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: