Provider Demographics
NPI:1780369256
Name:MANGEN, ELIZABETH J (PA-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:J
Last Name:MANGEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10920 COUNTY ROAD 9 NE
Mailing Address - Street 2:
Mailing Address - City:SPICER
Mailing Address - State:MN
Mailing Address - Zip Code:56288-9408
Mailing Address - Country:US
Mailing Address - Phone:320-894-5563
Mailing Address - Fax:
Practice Address - Street 1:10920 COUNTY ROAD 9 NE
Practice Address - Street 2:
Practice Address - City:SPICER
Practice Address - State:MN
Practice Address - Zip Code:56288-9408
Practice Address - Country:US
Practice Address - Phone:320-894-5563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-21
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.009875363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical