Provider Demographics
NPI:1376638569
Name:MAGO, JUDITH MARIE (PA)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:MARIE
Last Name:MAGO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:GOODLAND
Mailing Address - State:KS
Mailing Address - Zip Code:67735-1518
Mailing Address - Country:US
Mailing Address - Phone:785-890-4012
Mailing Address - Fax:785-890-6077
Practice Address - Street 1:106 WILLOW RD
Practice Address - Street 2:
Practice Address - City:GOODLAND
Practice Address - State:KS
Practice Address - Zip Code:67735-1518
Practice Address - Country:US
Practice Address - Phone:785-890-4012
Practice Address - Fax:785-890-6077
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO872363A00000X
KS1501352363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200631060AMedicaid
KS111003004OtherBCBS
P58102Medicare UPIN