Basic Information
| Provider Information | |||||||||
| NPI: | 1114998572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAGENNIS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 N 9TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FORT DODGE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 505013909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5155746890 | ||||||||
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| Practice Location | |||||||||
| Address1: | 115 S PARK AVE | ||||||||
| Address2: | |||||||||
| City: | EAGLE GROVE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 505332219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5154485185 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 09/25/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 000816 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.