Provider Demographics
NPI:1922858802
Name:MANGAN, ANDREW REYNOLDS
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:REYNOLDS
Last Name:MANGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 BLACKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72207-3420
Mailing Address - Country:US
Mailing Address - Phone:501-520-7484
Mailing Address - Fax:
Practice Address - Street 1:4301 W MARKHAM ST # 543
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:501-603-1214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program