Healthcare Provider Details

I. General information

NPI: 1447898846
Provider Name (Legal Business Name): EVAN KHRISTINE MANGUBAT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2019
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5169 S COTTONWOOD ST STE 420
MURRAY UT
84107-6769
US

IV. Provider business mailing address

2139 E BEECHWOOD AVE
FRESNO CA
93720-0340
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-1625
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13171808-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: