1558437756 NPI number — MRS. DIANNE M FAGAN R.D.

Table of content: MRS. DIANNE M FAGAN R.D. (NPI 1558437756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558437756 NPI number — MRS. DIANNE M FAGAN R.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAGAN
Provider First Name:
DIANNE
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
R.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558437756
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1184 ROSEHILL BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NISKAYUNA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12309-4624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-382-0327
Provider Business Mailing Address Fax Number:
518-381-9554

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2310 NOTT ST E
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
NISKAYUNA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12309-4303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-526-0004
Provider Business Practice Location Address Fax Number:
518-381-9554
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 968021 . This is a "MVP HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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