Provider Demographics
NPI:1720414949
Name:MANGO, SCOTT JOSEPH (CRNA)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:JOSEPH
Last Name:MANGO
Suffix:
Gender:M
Credentials:CRNA
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 660857
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0857
Mailing Address - Country:US
Mailing Address - Phone:855-709-4498
Mailing Address - Fax:302-733-0854
Practice Address - Street 1:1900 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-6880
Practice Address - Country:US
Practice Address - Phone:989-894-3000
Practice Address - Fax:989-891-0497
Is Sole Proprietor?:No
Enumeration Date:2013-09-19
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704206863367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI100680OtherAANA
MIP01290769OtherRAILROAD MEDICARE
MI0872871OtherBCBSM
MIP01290769OtherRAILROAD MEDICARE