Healthcare Provider Details

I. General information

NPI: 1316040660
Provider Name (Legal Business Name): KATHERINE JANE MANZANARES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 NORTH BEAUREGARD STREET, SUITE 250
ALEXANDRIA VA
22311-5879
US

IV. Provider business mailing address

224-D CORNWALL STREET, NW, SUITE 403
LEESBURG VA
20176-2704
US

V. Phone/Fax

Practice location:
  • Phone: 703-370-2400
  • Fax: 703-370-7214
Mailing address:
  • Phone: 703-737-6010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110003633
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA030510
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: