Healthcare Provider Details

I. General information

NPI: 1649353541
Provider Name (Legal Business Name): WAYNE FAGIN LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 13TH ST NE
SALEM OR
97301-2650
US

IV. Provider business mailing address

460 13TH ST NE
SALEM OR
97301-2650
US

V. Phone/Fax

Practice location:
  • Phone: 503-371-7655
  • Fax:
Mailing address:
  • Phone: 503-371-7655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number6031
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: