Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 72161 | MA |
N | 111NI0900X | Internist | 72161 | MA |
Y | 207RI0200X | Infectious Disease | 72161 | MA |
NPI | 1073638995 |
---|---|
Provider Name | Maura A Fagan |
First Address | Boston, MA 02118-2371 |
Second Address | Boston, MA 02118-2526 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/03/2007 |
Last Update Date | 12/05/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
110053951A | (05) | MA |
J1440601 | (02) | MA |