Healthcare Provider Details

I. General information

NPI: 1962588897
Provider Name (Legal Business Name): BRIAN MANN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 10/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7473 C HWY 22
WHISPERING PINES NC
28327-0000
US

IV. Provider business mailing address

PO BOX 843298
BOSTON MA
02284-3298
US

V. Phone/Fax

Practice location:
  • Phone: 910-215-5100
  • Fax: 910-215-5114
Mailing address:
  • Phone: 910-215-5100
  • Fax: 910-215-5114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50001829
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11548
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: