MEDICARE: MR. MARK JAYSON MANUEL FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	95034369	CA
2	163W00000X	Registered Nurse	95211746	CA

General Provider Information

NPI Number	:	1487454120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK JAYSON MANUEL FNP-C

Provider Business Mailing Address
First Line	:	5901 W OLYMPIC BLVD STE 505
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-4670
Country	:	US
Telephone Number	:	323-930-2324
Fax Number	:

Provider Business Practice Location Address
First Line	:	5901 W OLYMPIC BLVD STE 505
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-4670
Country	:	US
Telephone Number	:	323-930-2324
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2025
Last Update Date	:	12/09/2025

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