Provider Demographics
NPI:1902146657
Name:MANALANG, TEODORO RIO MONTEMAYOR (NP-C)
Entity Type:Individual
Prefix:MR
First Name:TEODORO RIO
Middle Name:MONTEMAYOR
Last Name:MANALANG
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SHADOW LN STE 106
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4355
Mailing Address - Country:US
Mailing Address - Phone:702-731-0909
Mailing Address - Fax:
Practice Address - Street 1:400 SHADOW LN STE 106
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4355
Practice Address - Country:US
Practice Address - Phone:702-731-0909
Practice Address - Fax:028-264-7677
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-18
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22779363L00000X
NVAPRN001535363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1902146657Medicaid