Provider Demographics
NPI:1629051537
Name:MANGROLA, UMENGSINH GAMELSINH (PA)
Entity Type:Individual
Prefix:
First Name:UMENGSINH
Middle Name:GAMELSINH
Last Name:MANGROLA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3768
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95344-3768
Mailing Address - Country:US
Mailing Address - Phone:209-723-3704
Mailing Address - Fax:209-723-0272
Practice Address - Street 1:374 W OLIVE AVE STE A
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-3181
Practice Address - Country:US
Practice Address - Phone:209-384-5766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16980363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1059963OtherNCCPA CERT #
CAMM1042819OtherDEA CERT
CA1059963OtherNCCPA CERT #
CAMM1042819OtherDEA CERT