Provider Demographics
NPI:1114998572
Name:MAGENNIS, MARK P (PAC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:P
Last Name:MAGENNIS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 N 9TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-3909
Mailing Address - Country:US
Mailing Address - Phone:515-574-6890
Mailing Address - Fax:
Practice Address - Street 1:115 S PARK AVE
Practice Address - Street 2:
Practice Address - City:EAGLE GROVE
Practice Address - State:IA
Practice Address - Zip Code:50533-2219
Practice Address - Country:US
Practice Address - Phone:515-448-5185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000816363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R80984Medicare UPIN
IAI3377Medicare PIN