Provider Demographics
NPI:1194340158
Name:MANGUM, TY DALLAS (PA)
Entity type:Individual
Prefix:MR
First Name:TY
Middle Name:DALLAS
Last Name:MANGUM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 W 600 N
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-2609
Mailing Address - Country:US
Mailing Address - Phone:435-680-2309
Mailing Address - Fax:
Practice Address - Street 1:595 W 600 N
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-2609
Practice Address - Country:US
Practice Address - Phone:435-680-2309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL085008692363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program