Provider Demographics
NPI:1508096256
Name:FITZGERALD, THERESA MANGAHAS (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MANGAHAS
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:DELA CRUZ
Other - Last Name:MANGAHAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-259-0966
Mailing Address - Fax:
Practice Address - Street 1:2925 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1321
Practice Address - Country:US
Practice Address - Phone:651-241-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-15
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60238357207Q00000X
MN70102207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine