Healthcare Provider Details

I. General information

NPI: 1265561377
Provider Name (Legal Business Name): MATTHEW ALLYN FAGERT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 SW RAMSEY AVE
GRANTS PASS OR
97527
US

IV. Provider business mailing address

2620 EAST BARNETT RD SUITE H
MEDFORD OR
97504
US

V. Phone/Fax

Practice location:
  • Phone: 541-472-7000
  • Fax:
Mailing address:
  • Phone: 541-789-5250
  • Fax: 541-789-5538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number200540820
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: