=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710701024
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES KRISTOPHER MANGRUM FNP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2024
-----------------------------------------------------
Last Update Date | 12/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10513 MARBACH RD STE 102
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78245-1995
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-290-8081
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6070 AKIN QUAY
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78261-4430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-391-9467
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1074871
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------