Provider Demographics
NPI:1891160644
Name:MANGACU, IRENE
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:MANGACU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4261 STEVENSON BLVD
Mailing Address - Street 2:APT. 286
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-2787
Mailing Address - Country:US
Mailing Address - Phone:805-302-6412
Mailing Address - Fax:
Practice Address - Street 1:2370 CARSON ST
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94061-2008
Practice Address - Country:US
Practice Address - Phone:805-302-6412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-04
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA697151163W00000X
CA95000476367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse