Provider Demographics
NPI:1124115126
Name:MAGNUSON, DEREK DOUGLAS (PA-C)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:DOUGLAS
Last Name:MAGNUSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7550 N DALE MABRY HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-3226
Mailing Address - Country:US
Mailing Address - Phone:813-885-4706
Mailing Address - Fax:813-885-9463
Practice Address - Street 1:7550 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-3226
Practice Address - Country:US
Practice Address - Phone:813-885-4706
Practice Address - Fax:813-885-9463
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101889363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q44131Medicare UPIN
FLQ44131Medicare UPIN