Healthcare Provider Details

I. General information

NPI: 1811502610
Provider Name (Legal Business Name): SHAKERA MANGAROO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3476 S UNIVERSITY DR
DAVIE FL
33328-2000
US

IV. Provider business mailing address

3476 S UNIVERSITY DR
DAVIE FL
33328-2000
US

V. Phone/Fax

Practice location:
  • Phone: 954-475-4400
  • Fax:
Mailing address:
  • Phone: 954-475-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: