MEDICARE: DR. JESSICA CONLON MANYAN D.O.

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	207Q00000X	Family Medicine Physician	0538	RI
2	207Q00000X	Family Medicine Physician	283425	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598762734
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSICA CONLON MANYAN D.O.

Provider Business Mailing Address
First Line	:	7 HOMESTEAD ST
Second Line	:
City	:	PAWTUCKET
State	:	RI
Zip	:	02860-4215
Country	:	US
Telephone Number	:	401-837-4503
Fax Number	:	508-673-5605

Provider Business Practice Location Address
First Line	:	67 SLADES FERRY AVE STE 6706
Second Line	:
City	:	SOMERSET
State	:	MA
Zip	:	02726-1220
Country	:	US
Telephone Number	:	508-678-5633
Fax Number	:	508-673-5605

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

Provider Enumeration Date	:	07/01/2005
Last Update Date	:	05/19/2022

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