Healthcare Provider Details

I. General information

NPI: 1205316452
Provider Name (Legal Business Name): ERIC T FAGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 N PIEDRAS ST
EL PASO TX
79930
US

IV. Provider business mailing address

5392 JACK MARCUS DR
EL PASO TX
79934-3185
US

V. Phone/Fax

Practice location:
  • Phone: 915-742-9485
  • Fax:
Mailing address:
  • Phone: 908-967-2308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: