Healthcare Provider Details

I. General information

NPI: 1346217841
Provider Name (Legal Business Name): LARRY G. MANNEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17705 HUTCHINS DR SUITE 101
MINNETONKA MN
55345-4145
US

IV. Provider business mailing address

17705 HUTCHINS DR SUITE 101
MINNETONKA MN
55345-4145
US

V. Phone/Fax

Practice location:
  • Phone: 952-401-8300
  • Fax: 952-401-8246
Mailing address:
  • Phone: 952-401-8300
  • Fax: 952-401-8246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number42337
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: