Healthcare Provider Details

I. General information

NPI: 1336122084
Provider Name (Legal Business Name): RICARDO ANTONIO MANGIONE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 SUNSET DR SUITE 403
SOUTH MIAMI FL
33143-4828
US

IV. Provider business mailing address

10314 SW 128TH CT
MIAMI FL
33186-2321
US

V. Phone/Fax

Practice location:
  • Phone: 305-740-8036
  • Fax: 305-740-8137
Mailing address:
  • Phone: 786-413-4051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9102135
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9102135
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: