Healthcare Provider Details

I. General information

NPI: 1609693852
Provider Name (Legal Business Name): KARA ROSE FAGERSTROM PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2024
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3151 WALBERT AVE STE 200
ALLENTOWN PA
18104-6042
US

IV. Provider business mailing address

3151 WALBERT AVE STE 200
ALLENTOWN PA
18104-6042
US

V. Phone/Fax

Practice location:
  • Phone: 484-526-1735
  • Fax: 484-526-2429
Mailing address:
  • Phone: 484-526-1735
  • Fax: 484-526-2429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA065979
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: