Basic Information
| Provider Information | |||||||||
| NPI: | 1659642783 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANNA | ||||||||
| FirstName: | FEBRIANTY | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | PANJAITAN | ||||||||
| OtherFirstName: | FEBRIANTY | ||||||||
| OtherMiddleName: | P | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 690 CANTON ST | ||||||||
| Address2: | STE 325 | ||||||||
| City: | WESTWOOD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020902324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814077713 | ||||||||
| FaxNumber: | 7814070998 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 W MINERAL KING AVE | ||||||||
| Address2: | |||||||||
| City: | VISALIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932916237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596242000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2012 | ||||||||
| LastUpdateDate: | 12/07/2016 | ||||||||
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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 | 367500000X | 679974 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.