Provider Demographics
NPI:1851091169
Name:MAGNUSON, CODY ALLEN
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:ALLEN
Last Name:MAGNUSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3610 E POWDER HORN RD
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-1577
Mailing Address - Country:US
Mailing Address - Phone:321-626-3004
Mailing Address - Fax:
Practice Address - Street 1:3610 E POWDER HORN RD
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-1577
Practice Address - Country:US
Practice Address - Phone:321-626-3004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program