Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204F00000X | Transplant Surgeon | 01059183A | IN |
NPI | 1316997869 |
---|---|
Provider Name | Richard Shane Mangus |
First Address | Indianapolis, IN 46202-5149 |
Second Address | Indianapolis, IN 46202-5149 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/05/2006 |
Last Update Date | 14/01/2021 |