Healthcare Provider Details

I. General information

NPI: 1871649921
Provider Name (Legal Business Name): MATTHEW J MANICO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2013 JEFFERSON ST SW FL 2
ROANOKE VA
24014-2419
US

IV. Provider business mailing address

2013 JEFFERSON ST SW FL 2
ROANOKE VA
24014-2419
US

V. Phone/Fax

Practice location:
  • Phone: 540-982-0237
  • Fax: 540-982-2719
Mailing address:
  • Phone: 540-982-0237
  • Fax: 540-982-2719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110840784
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: