Basic Information
| Provider Information | |||||||||
| NPI: | 1326583071 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANZANO | ||||||||
| FirstName: | JENAH | ||||||||
| MiddleName: | WESLEY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 WOLFSNARE LN | ||||||||
| Address2: | |||||||||
| City: | MORRISVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275607061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613765705 | ||||||||
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| Practice Location | |||||||||
| Address1: | 410 CANTERBURY RD | ||||||||
| Address2: | |||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275774861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199345149 | ||||||||
| FaxNumber: | 9199345632 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2017 | ||||||||
| LastUpdateDate: | 05/01/2019 | ||||||||
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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 | 363A00000X | 0010-06834 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.