Provider Demographics
NPI:1508583477
Name:MANGRA, ANNA MARIA
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:MARIA
Last Name:MANGRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 CORMAN AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:AL
Mailing Address - Zip Code:36081-3816
Mailing Address - Country:US
Mailing Address - Phone:334-733-3361
Mailing Address - Fax:
Practice Address - Street 1:102 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-2911
Practice Address - Country:US
Practice Address - Phone:334-793-8804
Practice Address - Fax:334-699-4473
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-21
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2120363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant