Healthcare Provider Details

I. General information

NPI: 1891848081
Provider Name (Legal Business Name): SUE FAGAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 SW STARK ST 8TH FLOOR
PORTLAND OR
97204-2347
US

IV. Provider business mailing address

619 NW 6TH AVE FL 5
PORTLAND OR
97209-3964
US

V. Phone/Fax

Practice location:
  • Phone: 503-988-3674
  • Fax: 503-988-5484
Mailing address:
  • Phone: 503-988-7468
  • Fax: 503-988-3015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number000032127N1
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: