MEDICARE: MS. MARILYN ANN MANGUS MS, ATC,R

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1285690917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARILYN ANN MANGUS MS, ATC,R

Provider Business Mailing Address
First Line	:	2330 WILSON DR
Second Line	:
City	:	EUGENE
State	:	OR
Zip	:	97405-1471
Country	:	US
Telephone Number	:	541-687-2331
Fax Number	:

Provider Business Practice Location Address
First Line	:	1232 UNIVERSITY OF OREGON
Second Line	:
City	:	EUGENE
State	:	OR
Zip	:	97403-1205
Country	:	US
Telephone Number	:	541-346-4150
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2006
Last Update Date	:	07/08/2007

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