Provider Demographics
NPI:1174548069
Name:MANALO, NEAL A (PA)
Entity type:Individual
Prefix:
First Name:NEAL
Middle Name:A
Last Name:MANALO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13300 HARGRAVE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-4374
Mailing Address - Country:US
Mailing Address - Phone:281-357-0111
Mailing Address - Fax:
Practice Address - Street 1:13300 HARGRAVE RD STE 300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-4374
Practice Address - Country:US
Practice Address - Phone:281-357-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840704363A00000X
TX11010363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA278243OtherANTHEM
MM0806767OtherDEA CERTIFICATE
MM0806767OtherDEA CERTIFICATE
970000245Medicare PIN