MEDICARE: MARY FAGO NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	109181	MA

General Provider Information

NPI Number	:	1093929713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY FAGO NP

Provider Business Mailing Address
First Line	:	66 ROE AVE
Second Line	:
City	:	NORTHAMPTON
State	:	MA
Zip	:	01060-1636
Country	:	US
Telephone Number	:	413-584-1732
Fax Number	:

Provider Business Practice Location Address
First Line	:	319 BEECH ST
Second Line	:	TEEN CLINIC
City	:	HOLYOKE
State	:	MA
Zip	:	01040-3968
Country	:	US
Telephone Number	:	413-534-2033
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2007
Last Update Date	:	12/18/2014

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