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NPI 1467578989 MANGUBAT ELMER ANTONIO DR. MD

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					                                                                                                                                                   HIPAASpace NPI Form
WWW.HIPAASPACE.COM                                                                                                                                    Source NPI Lookup


                              NATIONAL PROVIDER IDENTIFIER (NPI) FORM
Information provided in the current document is obtained from official source and accuracy of the information provided is the sole
responsibility of the healthcare provide. All changes, corrections or updates must be done through the official sources. Please contact
HIPAASpace.com in case you need the assistance in obtaining the official contacts of corresponding government organizations.

SECTION 1 – BASIC INFORMATION
 NPI Number          Provider (Organization) Full Name                  Provider (Organization) Other Name                         Entity Type          Replacement NPI

 1467578989           DR. MANGUBAT ELMER ANTONIO MD                                                                                Individual
 Gender        Enumeration Date     Last Update Date     Deactivation Reason Code      Deactivation Date       Reactivation Date    Employer Identification Number (EIN)

 Male          03/22/2007           07/08/2007

SECTION 2 – CONTACT INFORMATION
 Business Mailing Address

 16400 SOUTHCENTER PKWY SUITE 101, TUKWILA WA981883335-981883335 US
 Practice Location Address

 16400 SOUTHCENTER PKWY SUITE 101, TUKWILA WA981883335-981883335 US
 Business Phone Number                       Business Fax Number                            Practice Phone Number                            Practice Fax Number

 2065750300                                  2065751881                                     2065750300                                       2065751881
 Authorized Official – Name                                                         Authorized Official – Title/Position              Authorized Official - Phone Number




SECTION 3 – LICENSING, IDENTIFICATION INFORMATION

A. TAXONOMY INFORMATION

1. Code: 208200000X (Plastic Surgery). License Number : MD00032241 WA.




B. OTHER PROVIDER IDENTIFIERS

1. Identifier: O-131163. Type: MEDICARE UPIN. WA.




www.hipaaspace.com                                                    NPI Profile: 1467578989 DR. MANGUBAT ELMER ANTONIO MD

				
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