Provider Demographics
NPI:1407303340
Name:MANGEAC, OLIVIA ROCHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:ROCHELLE
Last Name:MANGEAC
Suffix:
Gender:F
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-6400
Mailing Address - Fax:208-302-6455
Practice Address - Street 1:3025 W CHERRY LN
Practice Address - Street 2:SUITE B
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8531
Practice Address - Country:US
Practice Address - Phone:208-302-6450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-08
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1387363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant