Provider Demographics
NPI:1386225605
Name:MANGALVEDKAR, MANU ACHYUT
Entity Type:Individual
Prefix:MR
First Name:MANU
Middle Name:ACHYUT
Last Name:MANGALVEDKAR
Suffix:
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 1:5272 11TH ST E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-2628
Mailing Address - Country:US
Mailing Address - Phone:863-602-7197
Mailing Address - Fax:
Practice Address - Street 1:1261 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2219
Practice Address - Country:US
Practice Address - Phone:941-366-1164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11012658367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered