Provider Demographics
NPI:1043758162
Name:MANGLICMOT, JEFFREY (CRNA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:MANGLICMOT
Suffix:
Gender:M
Credentials:CRNA
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 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-531-4522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP133234367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01815493OtherMEDICARE RAIL ROAD
TX75-0818167-015OtherTRICARE
TX8671UPOtherBCBS
TX369478801Medicaid
TX8671UPOtherBCBS