Individual
JEFFREY MANGLICMOT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
800 E DAWSON ST, TYLER, TX 75701-2036
(903) 531-4522
Mailing address
PO BOX 841656, DALLAS, TX 75284-1656
(903) 531-5000
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
AP133234
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
369478801
—
TX
01
—
75-0818167-015
TRICARE
TX
01
—
8671UP
BCBS
TX
01
—
P01815493
MEDICARE RAIL ROAD
TX
Enumeration date
02/09/2017
Last updated
07/21/2022
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