Healthcare Provider Details

I. General information

NPI: 1811596224
Provider Name (Legal Business Name): MARTHA FAGAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARTHA ADSIT

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MERIDIAN CENTRE BLVD STE 320
ROCHESTER NY
14618-3984
US

IV. Provider business mailing address

300 MERIDIAN CENTRE BLVD STE 320
ROCHESTER NY
14618-3984
US

V. Phone/Fax

Practice location:
  • Phone: 315-552-7763
  • Fax:
Mailing address:
  • Phone: 315-552-7763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number346047
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: