Provider Demographics
NPI:1407984842
Name:MAGID, LARISA (PA-C)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:MAGID
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 1:10906 WRIGHTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-3954
Mailing Address - Country:US
Mailing Address - Phone:310-429-0364
Mailing Address - Fax:
Practice Address - Street 1:18376 CLARK ST
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3502
Practice Address - Country:US
Practice Address - Phone:818-996-4077
Practice Address - Fax:818-996-4069
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17018363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ15334Medicare UPIN
CAPA17018Medicare ID - Type UnspecifiedPHYSICIAN ASSISTANT