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General NPI Number Information
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NPI Number | 1093078446
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Entity Type | Individual
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Provider Name | JAMES R MANGERSON PA-C
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Gender | Male
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Dates
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Enumeration Date | 06/20/2012
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Last Update Date | 01/27/2025
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Provider Practice Location Address
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Address Line | 515 NE GLEN OAK AVE STE 202
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City | PEORIA
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State | IL
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Zip | 61603-3166
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Country | US
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Telephone | 309-624-4455
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Fax | 309-624-3457
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Provider Business Mailing Address
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Address Line | 515 NE GLEN OAK AVE STE 202
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City | PEORIA
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State | IL
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Zip | 61603-3166
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Country | US
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Telephone | 309-624-4455
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Fax | 309-624-3457
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 2956
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 50.008880RX
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License Number State | OH
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 085010994
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License Number State | IL
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