Individual
MARY MOON MANZO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
19 FRIENDSHIP ST, NEWPORT, RI 02840-2272
(401) 849-6868
(401) 847-3840
Mailing address
2 DUDLEY ST, STE 200, PROVIDENCE, RI 02905-3248
(401) 849-6868
(401) 847-3840
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
PA 449
RI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
33279
BS
RI
01
—
414659
BLUE CHIP
RI
01
—
PA 449
RI LICENSE
RI
Enumeration date
08/17/2006
Last updated
02/16/2012
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