Provider Demographics
NPI:1093877896
Name:MAGNUSSEN, LARRY NORMAN (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:NORMAN
Last Name:MAGNUSSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3641 LAWAIUKA ROAD
Mailing Address - Street 2:
Mailing Address - City:LAWAI
Mailing Address - State:HI
Mailing Address - Zip Code:96765
Mailing Address - Country:US
Mailing Address - Phone:808-332-0779
Mailing Address - Fax:
Practice Address - Street 1:1 DANIEL BURNHAM CT STE 365-C
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-5490
Practice Address - Country:US
Practice Address - Phone:415-202-1920
Practice Address - Fax:415-922-6344
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG10995173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG10995OtherLICENSE
CAG10995OtherLICENSE