Provider Demographics
NPI:1487769386
Name:MANALASTAS, TRICIA (PA)
Entity type:Individual
Prefix:
First Name:TRICIA
Middle Name:
Last Name:MANALASTAS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23560 CRENSHAW BLVD.
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-1530
Mailing Address - Country:US
Mailing Address - Phone:310-784-2355
Mailing Address - Fax:310-517-1817
Practice Address - Street 1:2888 LONG BEACH BLVD.
Practice Address - Street 2:SUITE 180
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807
Practice Address - Country:US
Practice Address - Phone:562-595-5424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15922363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA43998Medicare UPIN
CAAQ977ZMedicare PIN