Basic Information
| Provider Information | |||||||||
| NPI: | 1558648550 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANALANG | ||||||||
| FirstName: | SHANE | ||||||||
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| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1703 TERMINO AVE STE 106 | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908042126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105520146 | ||||||||
| FaxNumber: | 3105520185 | ||||||||
| Practice Location | |||||||||
| Address1: | 3625 MARTIN LUTHER KING JR BLVD STE 5 | ||||||||
| Address2: | |||||||||
| City: | LYNWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902623509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5625088787 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2011 | ||||||||
| LastUpdateDate: | 02/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 21395 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.