Provider Demographics
NPI:1508929969
Name:MAGADAN, SUSAN L (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:MAGADAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:RUFNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 98978
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89193-8978
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:8285 W ARBY AVE STE 100B
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-2235
Practice Address - Country:US
Practice Address - Phone:702-735-7154
Practice Address - Fax:702-405-1860
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5548363A00000X
WI4103363A00000X
TXPA03559363A00000X
NVPA1953363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVPA1953OtherSTATE LICENSE
TX199127501Medicaid
NV1508929969Medicaid
AZ901489Medicaid