Healthcare Provider Details

I. General information

NPI: 1124466495
Provider Name (Legal Business Name): KEVIN PATRICK FAGAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2013
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 9TH AVE
SEATTLE WA
98101-2756
US

IV. Provider business mailing address

1100 9TH AVE M4-PFS
SEATTLE WA
98101-2756
US

V. Phone/Fax

Practice location:
  • Phone: 206-223-6980
  • Fax:
Mailing address:
  • Phone: 206-515-5811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP61017573
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN1020645
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: