Provider Demographics
NPI:1073206785
Name:FOSSO, MAGAN
Entity Type:Individual
Prefix:
First Name:MAGAN
Middle Name:
Last Name:FOSSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4102 AMHURST DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75077-3198
Mailing Address - Country:US
Mailing Address - Phone:940-312-9325
Mailing Address - Fax:
Practice Address - Street 1:1801 INWOOD RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7202
Practice Address - Country:US
Practice Address - Phone:214-645-0595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program