Provider Demographics
NPI:1750427902
Name:MAGNUSEN, MARY KATHLEEN (CRNA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:MAGNUSEN
Suffix:
Gender:F
Credentials:CRNA
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 3706
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3706
Mailing Address - Country:US
Mailing Address - Phone:866-907-1068
Mailing Address - Fax:425-917-9141
Practice Address - Street 1:1915 E REZANOF DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615
Practice Address - Country:US
Practice Address - Phone:907-486-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKNURA325367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered