Provider Demographics
NPI:1952352569
Name:MANGUBAT, ANTHONY D (PT)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:D
Last Name:MANGUBAT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 SCARLETT BLVD
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-8324
Mailing Address - Country:US
Mailing Address - Phone:850-277-0455
Mailing Address - Fax:
Practice Address - Street 1:1381C CROSS CREEK CIR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-3729
Practice Address - Country:US
Practice Address - Phone:850-656-3163
Practice Address - Fax:850-656-3463
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT10456225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist