Healthcare Provider Details

I. General information

NPI: 1649993817
Provider Name (Legal Business Name): TIMOTHY FAGERNESS CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2022
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 E 20TH ST STE 300
SIOUX FALLS SD
57105-1045
US

IV. Provider business mailing address

4000 E 52ND ST
SIOUX FALLS SD
57103-5448
US

V. Phone/Fax

Practice location:
  • Phone: 605-504-1100
  • Fax:
Mailing address:
  • Phone: 605-359-8547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberCP002523
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: