Healthcare Provider Details

I. General information

NPI: 1114991700
Provider Name (Legal Business Name): RYAN L FAGAN ATC LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7756 W. DELPHI PK. - 27
CONVERSE IN
46919
US

IV. Provider business mailing address

312 E HARRISON ST
SWAYZEE IN
46986-9570
US

V. Phone/Fax

Practice location:
  • Phone: 765-384-4381
  • Fax: 765-384-5414
Mailing address:
  • Phone: 765-922-7203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000566A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: