Provider Demographics
NPI:1669545679
Name:MANZO, ANDREA RENATE (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:RENATE
Last Name:MANZO
Suffix:
Gender:F
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 1535
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98401-1535
Mailing Address - Country:US
Mailing Address - Phone:253-761-4200
Mailing Address - Fax:253-383-3553
Practice Address - Street 1:1304 FAWCETT AVE STE 100
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1900
Practice Address - Country:US
Practice Address - Phone:253-761-4200
Practice Address - Fax:253-761-4201
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1647572085B0100X, 2085R0202X
WAMD000433852085B0100X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8878588OtherPTAN-CMBC
WA184431OtherLABOR AND INDUSTRIES/WC UNION AVENUE OPEN
WA0243528OtherLABOR AND INDUSTRIES-CAROL MILGARD BREAST CENTER
WA3231MAOtherREGENCE BLUE SHIELD TRA
OR500671257Medicaid
WA7251MAOtherREGENCE BLUE SHIELD UNION AVENUE OPEN
WA8411456Medicaid
WA8951848OtherLABOR AND INDUSTRIES CRIME VICTIMS-MEDICAL IMAGING ON 1ST
WAG8803535OtherPTAN-WESTERN STATE HOSPITAL
WA0249528OtherLABOR AND INDUSTRIES-MEDICAL IMAGING ON 1ST
WA184430OtherLABOR AND INDUSTRIES/WC TRA
WA8803056OtherMEDICARE PIN TRA KING COUNTY
WAP00689845OtherRR MEDICARE-CAROL MILGARD BREAST CENTER
WA8949635OtherLABOR AND INDUSTRIES CRIME VICTIMS-CAROL MILGARD BREAST CENTER
WAG8882929OtherPTAN-MIO1
WAG8927637OtherPTAN-UAOM
WA7251MAOtherREGENCE BLUE SHIELD UNION AVENUE OPEN