Healthcare Provider Details

I. General information

NPI: 1023006277
Provider Name (Legal Business Name): JON LOWELL FAGRE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 10/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 N SWING
AMES IA
50014-9472
US

IV. Provider business mailing address

5601 N SWING
AMES IA
50014-9472
US

V. Phone/Fax

Practice location:
  • Phone: 515-291-4353
  • Fax:
Mailing address:
  • Phone: 515-291-4353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number25021
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: