Provider Demographics
NPI:1629203575
Name:FRAGOSO, ELIZABETH MANGER (PT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MANGER
Last Name:FRAGOSO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10785 W TWAIN AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-3026
Mailing Address - Country:US
Mailing Address - Phone:725-726-7847
Mailing Address - Fax:725-726-7876
Practice Address - Street 1:9310 SUN CITY BLVD STE 103
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89134-1705
Practice Address - Country:US
Practice Address - Phone:725-726-7847
Practice Address - Fax:725-726-7876
Is Sole Proprietor?:No
Enumeration Date:2009-05-21
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1371225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1629203575Medicaid