Healthcare Provider Details

I. General information

NPI: 1942057765
Provider Name (Legal Business Name): AUSTIN FAGERBRG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2024
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 RED RIVER ST
AUSTIN TX
78701-1918
US

IV. Provider business mailing address

7120 KINGS ROW
AUSTIN TX
78746-5063
US

V. Phone/Fax

Practice location:
  • Phone: 512-324-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number783630
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: