Provider Demographics
NPI:1043462526
Name:MANGIAFICO, LORA A (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LORA
Middle Name:A
Last Name:MANGIAFICO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 271429
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-1429
Mailing Address - Country:US
Mailing Address - Phone:602-772-3800
Mailing Address - Fax:602-772-3801
Practice Address - Street 1:2940 E BANNER GATEWAY DR
Practice Address - Street 2:SUITE 200
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2168
Practice Address - Country:US
Practice Address - Phone:480-964-2908
Practice Address - Fax:480-833-2136
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAP2630363AS0400X
AZ6062363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000866601Medicare PIN