Healthcare Provider Details

I. General information

NPI: 1528962149
Provider Name (Legal Business Name): AMANDA FAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 2ND AVE W
WILLISTON ND
58801-2005
US

IV. Provider business mailing address

316 2ND AVE W
WILLISTON ND
58801-2005
US

V. Phone/Fax

Practice location:
  • Phone: 701-774-4600
  • Fax:
Mailing address:
  • Phone: 701-774-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: