Healthcare Provider Details

I. General information

NPI: 1376816520
Provider Name (Legal Business Name): AUSTEN FAGERLAND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2012
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 FLORMANN ST
RAPID CITY SD
57701-4679
US

IV. Provider business mailing address

353 FAIRMONT BLVD ATTEN CHRISTIE MSS
RAPID CITY SD
57701-7375
US

V. Phone/Fax

Practice location:
  • Phone: 605-718-3300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0810
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: