# BLACKHAWK MANGUM, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1093986937
- **Authorized official:** SHANA DAVENPORT (INSURANCE CREDENTIALING SUPERVISOR)
- **Authorized official phone:** (512) 681-3460

## Contact information

- **Practice address:** ONE WICKERSHAM DR, MANGUM, OK 73554
- **Practice address phone:** (580) 782-3353
- **Practice address fax:** (580) 782-2811
- **Mailing address:** PO BOX 280, MANGUM, OK 73554

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207P00000X | Emergency Medicine Physician | 2208 | OK | — |
| 207Q00000X | Family Medicine Physician | 2208 | OK | Yes |
| 363A00000X | Physician Assistant | 2208 | OK | — |
| 363LF0000X | Family Nurse Practitioner | 2208 | OK | — |

## Other

- **Enumeration date:** 03/19/2008
- **Last updated:** 07/23/2008