Healthcare Provider Details

I. General information

NPI: 1275639098
Provider Name (Legal Business Name): LEE MARSHALL FAGEN NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 BANCROFT EXT
BERKELEY CA
94720-4303
US

IV. Provider business mailing address

2727 HILLEGASS AVE
BERKELEY CA
94705-1206
US

V. Phone/Fax

Practice location:
  • Phone: 510-643-9135
  • Fax:
Mailing address:
  • Phone: 510-843-5326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN373234, NP7501
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: