Provider Demographics
NPI:1982197059
Name:MAGNUSON, BETHANY SUSANNE
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:SUSANNE
Last Name:MAGNUSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:SUSANNE
Other - Last Name:HOESCHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC, CSCS
Mailing Address - Street 1:721 BRENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-6607
Mailing Address - Country:US
Mailing Address - Phone:785-410-8246
Mailing Address - Fax:
Practice Address - Street 1:721 BRENTWOOD DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-6607
Practice Address - Country:US
Practice Address - Phone:785-410-8246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0705020372081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine