Healthcare Provider Details

I. General information

NPI: 1982804548
Provider Name (Legal Business Name): ROSS THOMAS MANGIN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 12/17/2021
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 SILAS CREEK PKWY
WINSTON SALEM NC
27103-3013
US

IV. Provider business mailing address

PO BOX 75332
CHARLOTTE NC
28275-0332
US

V. Phone/Fax

Practice location:
  • Phone: 800-899-5757
  • Fax: 314-821-1833
Mailing address:
  • Phone: 314-238-5260
  • Fax: 314-821-1833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-00979
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: