Healthcare Provider Details

I. General information

NPI: 1972700292
Provider Name (Legal Business Name): MARIANNE D MATSUGUMA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 N EUCLID ST STE 101
ANAHEIM CA
92801-4132
US

IV. Provider business mailing address

710 N EUCLID ST STE 400
ANAHEIM CA
92801-4122
US

V. Phone/Fax

Practice location:
  • Phone: 714-772-1030
  • Fax: 714-772-1758
Mailing address:
  • Phone: 714-517-2019
  • Fax: 714-300-0473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA13317
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: