Provider Demographics
NPI:1093078446
Name:MANGERSON, JAMES R (PAC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:MANGERSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 AMERICAN AVE
Mailing Address - Street 2:SUITE 510
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-5071
Mailing Address - Country:US
Mailing Address - Phone:262-928-5300
Mailing Address - Fax:262-928-5301
Practice Address - Street 1:721 AMERICAN AVE
Practice Address - Street 2:SUITE 510
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5071
Practice Address - Country:US
Practice Address - Phone:262-928-5300
Practice Address - Fax:262-928-5301
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2956363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
000068375Medicare PIN