Provider Demographics
NPI:1336753912
Name:MAGANA, FERNANDO MANRIQUEZ
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:MANRIQUEZ
Last Name:MAGANA
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 1:2185 MORNING GLORY ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-3546
Mailing Address - Country:US
Mailing Address - Phone:805-300-0867
Mailing Address - Fax:
Practice Address - Street 1:5241 NMAPLE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93740
Practice Address - Country:US
Practice Address - Phone:559-278-4240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1050274OtherNATA