Provider Demographics
NPI:1962657486
Name:MANGUM, SUSAN PATRICIA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:PATRICIA
Last Name:MANGUM
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2819 NW LOOP 410
Mailing Address - Street 2:STE A
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-5105
Mailing Address - Country:US
Mailing Address - Phone:210-225-3524
Mailing Address - Fax:210-225-2081
Practice Address - Street 1:2221 BUENA VISTA ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3702
Practice Address - Country:US
Practice Address - Phone:210-225-3524
Practice Address - Fax:210-225-2081
Is Sole Proprietor?:No
Enumeration Date:2008-11-25
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX515148363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily