Provider Demographics
NPI:1093117491
Name:MANGHAM, SARAH ANN
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:ANN
Last Name:MANGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8230 SUMMA AVE STE C
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3465
Mailing Address - Country:US
Mailing Address - Phone:225-757-0552
Mailing Address - Fax:
Practice Address - Street 1:5000 HENNESSY BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4375
Practice Address - Country:US
Practice Address - Phone:225-757-0552
Practice Address - Fax:225-763-9997
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200760363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical