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General NPI Number Information
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NPI Number | 1467764647
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Entity Type | Individual
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Provider Name | DERK LEE MANISCALCO DNP
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Gender | Male
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Dates
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Enumeration Date | 07/05/2010
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Last Update Date | 10/29/2019
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Provider Practice Location Address
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Address Line | 700 NE 87TH AVE
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City | VANCOUVER
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State | WA
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Zip | 98664
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Country | US
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Telephone | 360-397-3460
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Fax | 360-604-1761
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Provider Business Mailing Address
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Address Line | 15409 NE 89TH ST.
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City | VANCOUVER
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State | WA
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Zip | 98682-0000
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Country | US
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Telephone | 303-229-2418
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 201050075NP
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | AP60147803
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License Number State | WA
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