Healthcare Provider Details

I. General information

NPI: 1003677600
Provider Name (Legal Business Name): JONATHAN MANG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2910 SANTIAM HWY SE
ALBANY OR
97322-1400
US

IV. Provider business mailing address

2910 SANTIAM HWY SE
ALBANY OR
97322-1400
US

V. Phone/Fax

Practice location:
  • Phone: 541-406-3899
  • Fax:
Mailing address:
  • Phone: 541-406-3899
  • Fax: 458-250-6238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA228152
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: