Basic Information
Provider Information | |||||||||
NPI: | 1508864638 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAGNUSON | ||||||||
FirstName: | ALISE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | AMATO | ||||||||
OtherFirstName: | ALISE | ||||||||
OtherMiddleName: | MARY | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 825 N GRAND AVE STE 100 | ||||||||
Address2: |   | ||||||||
City: | NOGALES | ||||||||
State: | AZ | ||||||||
PostalCode: | 856211061 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5202811550 | ||||||||
FaxNumber: | 5202811112 | ||||||||
Practice Location | |||||||||
Address1: | 1103 CIRCULO MERCADO | ||||||||
Address2: |   | ||||||||
City: | NOGALES | ||||||||
State: | AZ | ||||||||
PostalCode: | 856486248 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5202811550 | ||||||||
FaxNumber: | 5202811112 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2005 | ||||||||
LastUpdateDate: | 05/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 0101233351 | VA | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | 63116 | AZ | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 098235 | 05 | AZ |   | MEDICAID |