TY DALLAS MANGUM Physician Assistant License verification

Business Entity

NOT RENEWED

License Type

Physician Assistant

Description

LICENSED PHYSICIAN ASSISTANT

License Number

085008692

License Status

NOT RENEWED

Business

First Name

Middle

DALLAS

Last Name

MANGUM

Business Name

TY DALLAS MANGUM

Original Issue Date

10/13/2021

Effective Date

02/15/2022

Expiration Date

03/01/2024

City

EVANSTON

State

Zip

60202

County

COOK

Ever Disciplined

LastModifiedDate

02/05/2025