Basic Information
| Provider Information | |||||||||
| NPI: | 1730539719 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANIUSZKO | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 350 NEW FIDELITY CT STE 500 | ||||||||
| Address2: | |||||||||
| City: | GARNER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275292665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192582714 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 109 W GANNON AVE STE 2 | ||||||||
| Address2: | |||||||||
| City: | ZEBULON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275972623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195515026 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2016 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305210404 | VA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 000023316 | MA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 1343109 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | P19626 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.