Provider Demographics
NPI:1417438227
Name:MANGUSON, JON MICHAEL
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:MICHAEL
Last Name:MANGUSON
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 1:1259 FAIRLAKE TRCE APT 201
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-2882
Mailing Address - Country:US
Mailing Address - Phone:407-307-8345
Mailing Address - Fax:
Practice Address - Street 1:1259 FAIRLAKE TRCE APT 201
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-2882
Practice Address - Country:US
Practice Address - Phone:407-307-8345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT32645225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist