Healthcare Provider Details

I. General information

NPI: 1245268820
Provider Name (Legal Business Name): MICHAEL A BUMANGLAG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 12/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9165 W THUNDERBIRD RD SUITE 200
PEORIA AZ
85381-4847
US

IV. Provider business mailing address

13640 N PLAZA DEL RIO BLVD
PEORIA AZ
85381-4846
US

V. Phone/Fax

Practice location:
  • Phone: 623-876-3870
  • Fax: 623-815-0087
Mailing address:
  • Phone: 623-876-3800
  • Fax: 623-876-6965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number3446
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: