Provider Demographics
NPI:1508864638
Name:MAGNUSON, ALISE (MD)
Entity Type:Individual
Prefix:DR
First Name:ALISE
Middle Name:
Last Name:MAGNUSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALISE
Other - Middle Name:MARY
Other - Last Name:AMATO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:825 N GRAND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85621-1061
Mailing Address - Country:US
Mailing Address - Phone:520-281-1550
Mailing Address - Fax:520-281-1112
Practice Address - Street 1:1103 CIRCULO MERCADO
Practice Address - Street 2:
Practice Address - City:NOGALES
Practice Address - State:AZ
Practice Address - Zip Code:85648-6248
Practice Address - Country:US
Practice Address - Phone:520-281-1550
Practice Address - Fax:520-281-1112
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233351208000000X
AZ63116208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ098235Medicaid
VA006736581Medicaid
H68545Medicare UPIN