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General NPI Number Information
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NPI Number | 1508864638
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Entity Type | Individual
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Provider Name | ALISE MAGNUSON M.D.
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Gender | Female
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Dates
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Enumeration Date | 07/12/2005
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Last Update Date | 05/26/2022
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Provider Practice Location Address
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Address Line | 1103 CIRCULO MERCADO
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City | NOGALES
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State | AZ
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Zip | 85648-6248
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Country | US
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Telephone | 520-281-1550
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Fax | 520-281-1112
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Provider Business Mailing Address
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Address Line | 825 N GRAND AVE STE 100
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City | NOGALES
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State | AZ
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Zip | 85621-1061
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Country | US
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Telephone | 520-281-1550
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Fax | 520-281-1112
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 0101233351
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 63116
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License Number State | AZ
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