Provider Demographics
NPI:1760815252
Name:MANGINO, MICHAEL WILLIAM JR (NP-P)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:MANGINO
Suffix:JR
Gender:M
Credentials:NP-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 COLLEGE RD
Mailing Address - Street 2:RIVERHEAD BUILDING
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-2851
Mailing Address - Country:US
Mailing Address - Phone:631-473-2453
Mailing Address - Fax:
Practice Address - Street 1:533 COLLEGE RD
Practice Address - Street 2:RIVERHEAD BUILDING
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-2851
Practice Address - Country:US
Practice Address - Phone:631-473-2453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY400716363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health