MEDICARE: YURY FAGANS RN

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	163W00000X	Registered Nurse	608685	NY

General Provider Information

NPI Number	:	1588891378
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YURY FAGANS RN

Provider Business Mailing Address
First Line	:	35 TULIP AVENUE
Second Line	:	PO BOX 20838
City	:	FLORAL PARK
State	:	NY
Zip	:	11002
Country	:	US
Telephone Number	:	917-862-5215
Fax Number	:	718-347-4643

Provider Business Practice Location Address
First Line	:	3841 18TH AVE APT 4E
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11218-6108
Country	:	US
Telephone Number	:	917-862-5215
Fax Number	:	718-347-4643

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

Provider Enumeration Date	:	06/18/2009
Last Update Date	:	06/18/2009

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