Provider Demographics
NPI:1679712053
Name:MANN, ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:MANN
Suffix:
Gender:F
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 1:365 MONTAUK AVE STE 2.013
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4700
Mailing Address - Country:US
Mailing Address - Phone:860-271-4275
Mailing Address - Fax:860-271-4278
Practice Address - Street 1:365 MONTAUK AVE STE 2.013
Practice Address - Street 2:LMH UROLOGY
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4700
Practice Address - Country:US
Practice Address - Phone:860-271-4275
Practice Address - Fax:860-271-4278
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-09
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA2591363A00000X
RIPA00482363AS0400X
CT4369363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant