Provider Demographics
NPI:1013341254
Name:MAGNO C. SANTOS MSN, FNP-C PLLC
Entity Type:Organization
Organization Name:MAGNO C. SANTOS MSN, FNP-C PLLC
Other - Org Name:SUNRISE MOBILE MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MAGNO
Authorized Official - Middle Name:C
Authorized Official - Last Name:SANTOS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:801-503-7712
Mailing Address - Street 1:2300 N YELLOWSTONE HWY STE 104
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-1662
Mailing Address - Country:US
Mailing Address - Phone:208-538-1963
Mailing Address - Fax:208-615-8005
Practice Address - Street 1:2300 N YELLOWSTONE HWY STE 104
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-1662
Practice Address - Country:US
Practice Address - Phone:208-538-1963
Practice Address - Fax:208-615-8005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-23
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDIDTPID015961Medicaid