Healthcare Provider Details

I. General information

NPI: 1306278551
Provider Name (Legal Business Name): SIOBHAN E FAGAN M.ED., AT, ATC, CSCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2013
Last Update Date: 07/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5911 IVY RIDGE RD
DAYTON OH
45431-2913
US

IV. Provider business mailing address

5911 IVY RIDGE RD
DAYTON OH
45431-2913
US

V. Phone/Fax

Practice location:
  • Phone: 937-602-0580
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT.002301
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: