Provider Demographics
NPI:1861450553
Name:MANGIN, GINA DELLACGUA (PAC)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:DELLACGUA
Last Name:MANGIN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7335 W SAND LAKE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-5538
Mailing Address - Country:US
Mailing Address - Phone:407-352-8553
Mailing Address - Fax:407-351-8412
Practice Address - Street 1:7335 W SAND LAKE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-5538
Practice Address - Country:US
Practice Address - Phone:407-352-8553
Practice Address - Fax:407-351-8412
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9104450363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0HS6OtherBCBS
FLCY908XMedicare PIN
GA349113009AMedicaid