Individual
ROBERT DYLAN MANGRUM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
3181 SW SAM JACKSON PARK RD, PORTLAND, OR 97239-3011
(503) 494-8311
Mailing address
3181 SW SAM JACKSON PARK RD, PORTLAND, OR 97239-3011
(503) 494-8311
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
PA9101478
FL
363AS0400X
Surgical Physician Assistant
Primary
PA172009
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1497748743
GROUP NPI NUMBER / LRHSI
FL
05
—
292286000
—
FL
05
—
500692609
—
OR
01
—
DA5786
RAILROAD MEDICARE GROUP NUMBER
FL
Enumeration date
05/18/2006
Last updated
11/16/2023
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