Provider Demographics
NPI:1316084056
Name:MANISTA, ANDREW PHILIP (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:PHILIP
Last Name:MANISTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507-0368
Mailing Address - Country:US
Mailing Address - Phone:360-491-8439
Mailing Address - Fax:360-491-6328
Practice Address - Street 1:404 YAUGER WAY SW
Practice Address - Street 2:SUITE 100
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8660
Practice Address - Country:US
Practice Address - Phone:360-786-8990
Practice Address - Fax:360-786-9010
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP17178207X00000X
WAMD60023058207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8521981Medicaid
WAMD60023058OtherWASHINGTON STATE
WA8521981Medicaid