Provider Demographics
NPI:1609806868
Name:MINGUEZ, JAYSON BAGAFORO (PT)
Entity Type:Individual
Prefix:MR
First Name:JAYSON
Middle Name:BAGAFORO
Last Name:MINGUEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:774 ROBINSON LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:75949-3229
Mailing Address - Country:US
Mailing Address - Phone:936-422-4295
Mailing Address - Fax:936-634-4825
Practice Address - Street 1:609 ELLIS AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3820
Practice Address - Country:US
Practice Address - Phone:936-634-4282
Practice Address - Fax:936-634-4825
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1121887225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F1949Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER