Healthcare Provider Details

I. General information

NPI: 1750903431
Provider Name (Legal Business Name): MS. KATHERINE ANNE FAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2428 SETTER RUN LN
STATE COLLEGE PA
16801-2577
US

IV. Provider business mailing address

2428 SETTER RUN LN
STATE COLLEGE PA
16801-2577
US

V. Phone/Fax

Practice location:
  • Phone: 814-954-0143
  • Fax:
Mailing address:
  • Phone: 814-954-0143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: