1669545679 NPI number — DR. ANDREA RENATE MANZO MD

Table of content: LISBET YOBANA VERDIN (NPI 1265008346)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669545679 NPI number — DR. ANDREA RENATE MANZO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANZO
Provider First Name:
ANDREA
Provider Middle Name:
RENATE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669545679
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1535
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98401-1535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-761-4200
Provider Business Mailing Address Fax Number:
253-383-3553

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1304 FAWCETT AVE STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98402-1900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-761-4200
Provider Business Practice Location Address Fax Number:
253-761-4201
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085B0100X , with the licence number:  MD164757 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085B0100X , with the licence number: MD00043385 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: MD164757 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: MD00043385 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: G8878588 . This is a "PTAN-CMBC" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 184431 . This is a "LABOR AND INDUSTRIES/WC UNION AVENUE OPEN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0243528 . This is a "LABOR AND INDUSTRIES-CAROL MILGARD BREAST CENTER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 3231MA . This is a "REGENCE BLUE SHIELD TRA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 500671257 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7251MA . This is a "REGENCE BLUE SHIELD UNION AVENUE OPEN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8411456 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8951848 . This is a "LABOR AND INDUSTRIES CRIME VICTIMS-MEDICAL IMAGING ON 1ST" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: G8803535 . This is a "PTAN-WESTERN STATE HOSPITAL" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0249528 . This is a "LABOR AND INDUSTRIES-MEDICAL IMAGING ON 1ST" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 184430 . This is a "LABOR AND INDUSTRIES/WC TRA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8803056 . This is a "MEDICARE PIN TRA KING COUNTY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: P00689845 . This is a "RR MEDICARE-CAROL MILGARD BREAST CENTER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8949635 . This is a "LABOR AND INDUSTRIES CRIME VICTIMS-CAROL MILGARD BREAST CENTER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: G8882929 . This is a "PTAN-MIO1" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: G8927637 . This is a "PTAN-UAOM" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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