Healthcare Provider Details

I. General information

NPI: 1861864654
Provider Name (Legal Business Name): LINDA NADINE FAGAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2015
Last Update Date: 10/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 INDEPENDENCE DR
BASKING RIDGE NJ
07920-3815
US

IV. Provider business mailing address

24 INDEPENDENCE DR
BASKING RIDGE NJ
07920-3815
US

V. Phone/Fax

Practice location:
  • Phone: 908-462-4620
  • Fax:
Mailing address:
  • Phone: 908-462-4620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number25MA07530800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: