Basic Information
| Provider Information | |||||||||
| NPI: | 1871730101 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANTO | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | HUGH | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 935 BUNGALOW CT | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466781174 | ||||||||
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| Practice Location | |||||||||
| Address1: | 220 E. ROGERS RD | ||||||||
| Address2: | |||||||||
| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037763250 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2009 | ||||||||
| LastUpdateDate: | 10/22/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 2892 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 81686048 | 05 | CO | MEDICAID |