Provider Demographics
NPI:1366163214
Name:MANGAOANG, JOHN NIKKO GABUYA (DPT)
Entity type:Individual
Prefix:
First Name:JOHN NIKKO
Middle Name:GABUYA
Last Name:MANGAOANG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 ALBEMARLE DR STE 1100
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-5945
Mailing Address - Country:US
Mailing Address - Phone:318-828-1450
Mailing Address - Fax:318-828-2697
Practice Address - Street 1:670 ALBEMARLE DR STE 1100
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-5945
Practice Address - Country:US
Practice Address - Phone:318-828-1450
Practice Address - Fax:318-828-2697
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11349225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty