Provider Demographics
NPI:1194003228
Name:MANCAO, MIGUEL III
Entity Type:Individual
Prefix:MR
First Name:MIGUEL
Middle Name:
Last Name:MANCAO
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 RITA RAE LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-2526
Mailing Address - Country:US
Mailing Address - Phone:850-485-0141
Mailing Address - Fax:
Practice Address - Street 1:10199 SOUTHSIDE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-0757
Practice Address - Country:US
Practice Address - Phone:321-422-7402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA-200367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant