Healthcare Provider Details

I. General information

NPI: 1588025282
Provider Name (Legal Business Name): SEAN FAGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2016
Last Update Date: 03/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 WESTERN AVE
GLOUCESTER MA
01930-3645
US

IV. Provider business mailing address

10 WESTERN AVE
GLOUCESTER MA
01930-3645
US

V. Phone/Fax

Practice location:
  • Phone: 978-381-5636
  • Fax:
Mailing address:
  • Phone: 978-381-5636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number12492
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: