Basic Information
| Provider Information | |||||||||
| NPI: | 1245268820 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUMANGLAG | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13640 N PLAZA DEL RIO BLVD | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238763800 | ||||||||
| FaxNumber: | 6238766965 | ||||||||
| Practice Location | |||||||||
| Address1: | 9165 W THUNDERBIRD RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238763870 | ||||||||
| FaxNumber: | 6238150087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 12/03/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 3446 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 3446 | 01 | AZ | STATE LICENSE | OTHER | 164595 | 05 | AZ | MEDICAID |