Provider Demographics
NPI:1518171529
Name:MAGNO, MICHAEL B (LPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:MAGNO
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1068
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507-1068
Mailing Address - Country:US
Mailing Address - Phone:360-438-1460
Mailing Address - Fax:360-438-1683
Practice Address - Street 1:3775 MARTIN WAY E STE A
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5007
Practice Address - Country:US
Practice Address - Phone:360-438-1460
Practice Address - Fax:360-438-1683
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00005011225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA183734OtherLABOR & INDUSTRIES
WA8385833Medicaid
WAQ52816Medicare UPIN
WA8385833Medicaid