Healthcare Provider Details

I. General information

NPI: 1043372675
Provider Name (Legal Business Name): MICHAEL MAGENNIS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 12/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 E 'D' STREET
DEER PARK WA
99006-0742
US

IV. Provider business mailing address

910 N WASHINGTON ST SUITE 209
SPOKANE WA
99201-2202
US

V. Phone/Fax

Practice location:
  • Phone: 509-276-5061
  • Fax:
Mailing address:
  • Phone: 509-232-1173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP30005199
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: