Healthcare Provider Details

I. General information

NPI: 1215940994
Provider Name (Legal Business Name): CAROLYN W FAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2954 RODEO PARK DR W
SANTA FE NM
87505-6351
US

IV. Provider business mailing address

8 CLEMATIS CIR
SANTA FE NM
87506-1292
US

V. Phone/Fax

Practice location:
  • Phone: 505-424-0131
  • Fax:
Mailing address:
  • Phone: 505-424-0131
  • Fax: 505-424-1299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number#456
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: