Healthcare Provider Details

I. General information

NPI: 1669487161
Provider Name (Legal Business Name): LYLE JAMES FAGNAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 SW VERMONT ST
PORTLAND OR
97219-1020
US

IV. Provider business mailing address

3181 SW SAM JACKSON PARK RD L222
PORTLAND OR
97239-3011
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-9992
  • Fax:
Mailing address:
  • Phone: 503-494-1582
  • Fax: 503-494-1513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD10673
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: