Provider Demographics
NPI:1164533618
Name:MANGOLD, DAVID E (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:E
Last Name:MANGOLD
Suffix:
Gender:M
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 1:20 FOUR MILE DR STE 2
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-2644
Mailing Address - Country:US
Mailing Address - Phone:406-300-4882
Mailing Address - Fax:406-257-2706
Practice Address - Street 1:20 FOUR MILE DR STE 2
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-2644
Practice Address - Country:US
Practice Address - Phone:406-300-4882
Practice Address - Fax:406-257-2706
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT323363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000094853OtherBC/BS
MT4302139Medicaid
MT000094853OtherBC/BS
MTP86552Medicare UPIN