Provider Demographics
NPI:1063134518
Name:GANZON, EMMANUELLE MARIE MARIANO
Entity type:Individual
Prefix:MS
First Name:EMMANUELLE MARIE
Middle Name:MARIANO
Last Name:GANZON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11288 PHILLIPPI AVE
Mailing Address - Street 2:
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-1519
Mailing Address - Country:US
Mailing Address - Phone:213-327-7828
Mailing Address - Fax:
Practice Address - Street 1:607 S ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:EAST LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-3211
Practice Address - Country:US
Practice Address - Phone:213-327-7828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical