Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2080P0202X | Pediatric Cardiologist | 44826 | CO |
N | 2080P0202X | Pediatric Cardiologist | 53605 | TN |
Y | 2080P0202X | Pediatric Cardiologist | G174751 | CA |
NPI | 1134116494 |
---|---|
Provider Name | Thomas Fagan |
First Address | Madera, CA 93636-8761 |
Second Address | Madera, CA 93636-8761 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/10/2005 |
Last Update Date | 15/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
30488001 | (05) | CO |