Provider Demographics
NPI:1669845186
Name:DE LA ROSA, MAGDIEL (AGACNP)
Entity Type:Individual
Prefix:
First Name:MAGDIEL
Middle Name:
Last Name:DE LA ROSA
Suffix:
Gender:M
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 W SUNFLOWER AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-6945
Mailing Address - Country:US
Mailing Address - Phone:888-789-9585
Mailing Address - Fax:
Practice Address - Street 1:3401 W SUNFLOWER AVE STE 250
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-6945
Practice Address - Country:US
Practice Address - Phone:888-789-9585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX465406YM8AMedicare PIN