Provider Demographics
NPI:1437971561
Name:MANALO, MARVIN GIL
Entity type:Individual
Prefix:
First Name:MARVIN GIL
Middle Name:
Last Name:MANALO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16362 SHAMHART DR
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-2834
Mailing Address - Country:US
Mailing Address - Phone:818-390-0804
Mailing Address - Fax:
Practice Address - Street 1:459 S AZUSA AVE STE F
Practice Address - Street 2:
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702-4945
Practice Address - Country:US
Practice Address - Phone:626-804-7169
Practice Address - Fax:626-804-7265
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-29
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95032534363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily