Provider Demographics
NPI:1083907505
Name:MANGCOY, MED MYRA F (PT)
Entity Type:Individual
Prefix:
First Name:MED MYRA
Middle Name:F
Last Name:MANGCOY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MED MYRA
Other - Middle Name:M
Other - Last Name:FRANI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:410 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:WALLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07057-1720
Mailing Address - Country:US
Mailing Address - Phone:646-321-3661
Mailing Address - Fax:
Practice Address - Street 1:2 ARNOT ST STE 3
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:NJ
Practice Address - Zip Code:07644-1630
Practice Address - Country:US
Practice Address - Phone:646-321-3661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
NJ40QA01202100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist