Provider Demographics
NPI:1669791034
Name:MANAGBANAG, JAN
Entity type:Individual
Prefix:MRS
First Name:JAN
Middle Name:
Last Name:MANAGBANAG
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JAN
Other - Middle Name:
Other - Last Name:SUTTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD, LD
Mailing Address - Street 1:11846 ABBOTTSWOOD ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-3005
Mailing Address - Country:US
Mailing Address - Phone:210-269-7044
Mailing Address - Fax:
Practice Address - Street 1:11846 ABBOTTSWOOD ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-3005
Practice Address - Country:US
Practice Address - Phone:210-269-7044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX862061133V00000X
TXDT05066133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal