Healthcare Provider Details

I. General information

NPI: 1891270831
Provider Name (Legal Business Name): ANNA FAGAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2018
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N ORANGE ST
MISSOULA MT
59802-2998
US

IV. Provider business mailing address

900 N ORANGE ST
MISSOULA MT
59802-2998
US

V. Phone/Fax

Practice location:
  • Phone: 406-329-5776
  • Fax:
Mailing address:
  • Phone: 406-329-5776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN-27623
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: