Healthcare Provider Details

I. General information

NPI: 1750527362
Provider Name (Legal Business Name): CHRISTOPHER ROBERT FAGERNESS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2009
Last Update Date: 01/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

498 4TH AVE NE
SIOUX CENTER IA
51250-1606
US

IV. Provider business mailing address

2800 PIERCE ST
SIOUX CITY IA
51104-3755
US

V. Phone/Fax

Practice location:
  • Phone: 712-722-6312
  • Fax:
Mailing address:
  • Phone: 605-421-9835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number00438
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: