Healthcare Provider Details

I. General information

NPI: 1710584818
Provider Name (Legal Business Name): PATRICIA MARIE FAGEN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2020
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2175 N WHITLEY DR
FRUITLAND ID
83619-2132
US

IV. Provider business mailing address

7625 N NEVADA AVE
FRUITLAND ID
83619-3559
US

V. Phone/Fax

Practice location:
  • Phone: 208-452-0303
  • Fax:
Mailing address:
  • Phone: 208-739-0463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1068
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: