Basic Information
| Provider Information | |||||||||
| NPI: | 1275584880 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANATIS | ||||||||
| FirstName: | ANNA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MANATIS-LORNELL | ||||||||
| OtherFirstName: | ANNA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 433 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HYANNIS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026013644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087784777 | ||||||||
| FaxNumber: | 5087719555 | ||||||||
| Practice Location | |||||||||
| Address1: | 795 BRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | NORTH WEYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021912139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813374105 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 10/25/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 70388 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3048161 | 05 | MA | MEDICAID |