Provider Demographics
NPI:1336991686
Name:MAGO, GINA LEE
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:LEE
Last Name:MAGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8391 CASTILIAN DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-6109
Mailing Address - Country:US
Mailing Address - Phone:714-745-5764
Mailing Address - Fax:
Practice Address - Street 1:3687 VETERANS DR
Practice Address - Street 2:
Practice Address - City:FORT HARRISON
Practice Address - State:MT
Practice Address - Zip Code:59636-9700
Practice Address - Country:US
Practice Address - Phone:406-447-7182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA152028164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse