Provider Demographics
NPI:1861705683
Name:MANGUBAT, MICHAEL KRISTIAN (PT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL KRISTIAN
Middle Name:
Last Name:MANGUBAT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 LITCHULT CT
Mailing Address - Street 2:
Mailing Address - City:AIRMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10901-7511
Mailing Address - Country:US
Mailing Address - Phone:347-605-7946
Mailing Address - Fax:
Practice Address - Street 1:825 WALTON AVENUE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-2306
Practice Address - Country:US
Practice Address - Phone:718-585-0888
Practice Address - Fax:718-585-0880
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-21
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029005225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics