Provider Demographics
NPI:1316046931
Name:MAGNUSON, MARTHA MACDOUGAL (PA-C)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:MACDOUGAL
Last Name:MAGNUSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARTH
Other - Middle Name:R
Other - Last Name:MACDOUGAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:913 E 26TH ST STE 600
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-4515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3580 ARCADE ST
Practice Address - Street 2:
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55127
Practice Address - Country:US
Practice Address - Phone:651-968-5770
Practice Address - Fax:651-968-5775
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10433363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432035899Medicaid
ME1316046931OtherTRICARE
ME010453642OtherGREATWEST
ME432035899Medicaid