=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568427219
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILE MANANSALA PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2006
-----------------------------------------------------
Last Update Date | 06/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 525 N 18TH ST SUITE 301
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-252-1510
-----------------------------------------------------
Fax | 602-256-9488
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 525 N 18TH ST SUITE 301
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-252-1510
-----------------------------------------------------
Fax | 602-256-9488
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 2356
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------