Provider Demographics
NPI:1144253113
Name:MAGNINE, NANCY LEE (PA-C)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:LEE
Last Name:MAGNINE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-8364
Mailing Address - Fax:
Practice Address - Street 1:1101 9TH ST N
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2329
Practice Address - Country:US
Practice Address - Phone:218-741-0150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12518363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI00496OtherMEDICARE GROUP
501P2MAOtherBCBS MN
WI0058OtherMEDICARE SEQUENCE #
1047665OtherPREFERRED ONE
WI42886500Medicaid
WI49170OtherMEDICARE GROUP
WI49170OtherMEDICARE GROUP