Basic Information
| Provider Information | |||||||||
| NPI: | 1437290038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANNING | ||||||||
| FirstName: | KATHLEEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1425 S MAIN ST | ||||||||
| Address2: | MOB 2 THIRD FLOOR | ||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945965318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252954110 | ||||||||
| FaxNumber: | 9252957234 | ||||||||
| Practice Location | |||||||||
| Address1: | 1425 S MAIN ST | ||||||||
| Address2: | MOB 2 THIRD FLOOR | ||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945965318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252954110 | ||||||||
| FaxNumber: | 9252957234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 12/20/2021 | ||||||||
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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 | 208600000X | MD00044301 | WA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 8412041 | 05 | WA | MEDICAID |