Provider Demographics
NPI:1972700292
Name:MATSUGUMA, MARIANNE D (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MARIANNE
Middle Name:D
Last Name:MATSUGUMA
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 1:710 N EUCLID ST STE 400
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-4122
Mailing Address - Country:US
Mailing Address - Phone:714-517-2019
Mailing Address - Fax:714-300-0473
Practice Address - Street 1:710 N EUCLID ST STE 101
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-4132
Practice Address - Country:US
Practice Address - Phone:714-772-1030
Practice Address - Fax:714-772-1758
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13317363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1750436473OtherNPI