=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275045304
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH MANILLA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2017
-----------------------------------------------------
Last Update Date | 06/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 717 LIBERTY AVE APT 2209 SUITE 200 CWING
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15222-3537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-456-6209
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3317 PARK RD APT O SUITE 200 CWING
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28209-2088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 119938
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------