Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | MT219074 | PA |
N | 208D00000X | General Practice Physician | 87682 | GA |
NPI | 1003476250 |
---|---|
Provider Name | Meenakumari Manoharan |
First Address | Fountain Hill, PA 18015-1000 |
Second Address | Fountain Hill, PA 18015-1000 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/06/2019 |
Last Update Date | 05/05/2021 |