Provider Demographics
NPI:1659700599
Name:MANGIO, ED FORTUNE AGUILOS (AGNP-BC)
Entity Type:Individual
Prefix:
First Name:ED FORTUNE
Middle Name:AGUILOS
Last Name:MANGIO
Suffix:
Gender:M
Credentials:AGNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6001 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1502
Mailing Address - Country:US
Mailing Address - Phone:614-234-6000
Mailing Address - Fax:
Practice Address - Street 1:800 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-3487
Practice Address - Country:US
Practice Address - Phone:781-278-6260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-01
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.15334363LA2200X
OK110868363LA2200X
MA2304159363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health