Healthcare Provider Details

I. General information

NPI: 1588193940
Provider Name (Legal Business Name): LUCAS RICHARD FANGMANN DPT, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 QUAKER MILL DR
MANCHESTER IA
52057
US

IV. Provider business mailing address

313 QUAKER MILL DR
MANCHESTER IA
52057-1052
US

V. Phone/Fax

Practice location:
  • Phone: 563-608-3343
  • Fax:
Mailing address:
  • Phone: 563-608-3343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: