Provider Demographics
NPI:1699787168
Name:JULIA MANGAN, FNP, FAMILY PRACTICE CLINIC P.C
Entity type:Organization
Organization Name:JULIA MANGAN, FNP, FAMILY PRACTICE CLINIC P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:B
Authorized Official - Last Name:MANGAN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:208-664-8818
Mailing Address - Street 1:1112 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2474
Mailing Address - Country:US
Mailing Address - Phone:208-664-8818
Mailing Address - Fax:208-664-4427
Practice Address - Street 1:1112 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2474
Practice Address - Country:US
Practice Address - Phone:208-664-8818
Practice Address - Fax:208-664-4427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP334A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805117600Medicaid
ID805117600Medicaid
ID1341821Medicare PIN