Provider Demographics
NPI:1366078206
Name:MANOS, ETHAN RICHARD (PA-C)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:RICHARD
Last Name:MANOS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 WOODVIEW WAY UNIT A23
Mailing Address - Street 2:
Mailing Address - City:HOPKINTON
Mailing Address - State:MA
Mailing Address - Zip Code:01748-2860
Mailing Address - Country:US
Mailing Address - Phone:857-772-9380
Mailing Address - Fax:
Practice Address - Street 1:115 CASS AVE
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-4705
Practice Address - Country:US
Practice Address - Phone:401-769-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-22
Last Update Date:2020-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty