Healthcare Provider Details

I. General information

NPI: 1548423817
Provider Name (Legal Business Name): LANDREY FAGAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3434 47TH ST STE 225
BOULDER CO
80301-1880
US

IV. Provider business mailing address

1950 MOUNTAIN VIEW AVE
LONGMONT CO
80501-3129
US

V. Phone/Fax

Practice location:
  • Phone: 720-792-2852
  • Fax: 303-586-7592
Mailing address:
  • Phone: 303-651-5111
  • Fax: 303-678-4050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR0060345
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberDR.0060345
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0060345
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number246674
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: