Healthcare Provider Details

I. General information

NPI: 1316370224
Provider Name (Legal Business Name): PATRICK DANIEL FAGAN D.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2013
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 WALL ST SUITE 110
SAINT CHARLES MO
63303-3539
US

IV. Provider business mailing address

1551 WALL ST SUITE 110
SAINT CHARLES MO
63303-3539
US

V. Phone/Fax

Practice location:
  • Phone: 636-669-2345
  • Fax: 636-669-2344
Mailing address:
  • Phone: 636-669-2345
  • Fax: 636-669-2344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2012037663
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: