Provider Demographics
NPI:1528735339
Name:MANZANO, REY KENNETH (FNP-BC, NP-C)
Entity type:Individual
Prefix:
First Name:REY
Middle Name:KENNETH
Last Name:MANZANO
Suffix:
Gender:M
Credentials:FNP-BC, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 S EAST AVE
Mailing Address - Street 2:FRESNO
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93706
Mailing Address - Country:US
Mailing Address - Phone:559-499-2400
Mailing Address - Fax:
Practice Address - Street 1:2555 S EAST AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-5104
Practice Address - Country:US
Practice Address - Phone:559-499-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-28
Last Update Date:2022-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018083363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily