Provider Demographics
NPI:1134979495
Name:MANGUM, ETHAN RAFAEL
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:RAFAEL
Last Name:MANGUM
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 1:1172 W SERAPHIM CT
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-2213
Mailing Address - Country:US
Mailing Address - Phone:385-439-3790
Mailing Address - Fax:
Practice Address - Street 1:1172 W SERAPHIM CT
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-2213
Practice Address - Country:US
Practice Address - Phone:385-439-3790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program