Healthcare Provider Details

I. General information

NPI: 1982197059
Provider Name (Legal Business Name): BETHANY SUSANNE MAGNUSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BETHANY SUSANNE HOESCHEN ATC, CSCS

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 06/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 BRENTWOOD DR
SANTA ROSA CA
95405-6607
US

IV. Provider business mailing address

721 BRENTWOOD DR
SANTA ROSA CA
95405-6607
US

V. Phone/Fax

Practice location:
  • Phone: 785-410-8246
  • Fax:
Mailing address:
  • Phone: 785-410-8246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number070502037
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: