Healthcare Provider Details

I. General information

NPI: 1720221864
Provider Name (Legal Business Name): MAUREEN FAGEN P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2009
Last Update Date: 04/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

452 BARD AVE
STATEN ISLAND NY
10310-2104
US

IV. Provider business mailing address

452 BARD AVE
STATEN ISLAND NY
10310-2104
US

V. Phone/Fax

Practice location:
  • Phone: 718-727-2441
  • Fax:
Mailing address:
  • Phone: 718-727-2441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5812
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: