Healthcare Provider Details

I. General information

NPI: 1841210648
Provider Name (Legal Business Name): MELISSA CHRISTINE FAGEN P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1965 FORD PKWY
SAINT PAUL MN
55116-1923
US

IV. Provider business mailing address

5058 250TH AVE
GRANITE FALLS MN
56241-3665
US

V. Phone/Fax

Practice location:
  • Phone: 651-696-5509
  • Fax:
Mailing address:
  • Phone: 320-564-4843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number893
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: