Healthcare Provider Details

I. General information

NPI: 1588891378
Provider Name (Legal Business Name): YURY FAGANS RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2009
Last Update Date: 06/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3841 18TH AVE APT 4E
BROOKLYN NY
11218-6108
US

IV. Provider business mailing address

35 TULIP AVENUE PO BOX 20838
FLORAL PARK NY
11002
US

V. Phone/Fax

Practice location:
  • Phone: 917-862-5215
  • Fax: 718-347-4643
Mailing address:
  • Phone: 917-862-5215
  • Fax: 718-347-4643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number608685
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: