Provider Demographics
NPI:1992792758
Name:MANLEY, KURTIS A (PA-C)
Entity type:Individual
Prefix:
First Name:KURTIS
Middle Name:A
Last Name:MANLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2226 HUALAPAI MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-8374
Mailing Address - Country:US
Mailing Address - Phone:928-681-8530
Mailing Address - Fax:928-681-8531
Practice Address - Street 1:2226 HUALAPAI MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-8374
Practice Address - Country:US
Practice Address - Phone:928-681-8530
Practice Address - Fax:928-681-8531
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 16493363A00000X
AZ4423363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant