Basic Information
| Provider Information | |||||||||
| NPI: | 1306049267 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAGINAS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CHRISTINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | C.N.P., R.N. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TIBBS | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | CHRISTINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | C.N.P., R.N. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3020 CHILDRENS WAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589668801 | ||||||||
| FaxNumber: | 8589667508 | ||||||||
| Practice Location | |||||||||
| Address1: | 3020 CHILDRENS WAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589668801 | ||||||||
| FaxNumber: | 8589667508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2007 | ||||||||
| LastUpdateDate: | 08/23/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 191418-2 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363L00000X | NP17231 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 163W00000X | RN698472 | CA | N | Nursing Service Providers | Registered Nurse | 163W00000X | 191418-2 | MN | N | Nursing Service Providers | Registered Nurse |
No ID Information.