Provider Demographics
NPI:1255472692
Name:FAGAN, CHERI LEIGH (OTRL)
Entity Type:Individual
Prefix:
First Name:CHERI
Middle Name:LEIGH
Last Name:FAGAN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:CHERI
Other - Middle Name:LEIGH
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:PO BOX 384
Mailing Address - Street 2:306 EAST 1ST ST
Mailing Address - City:MIFFLINVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18631
Mailing Address - Country:US
Mailing Address - Phone:570-752-4744
Mailing Address - Fax:
Practice Address - Street 1:221 W TAMARACK ST
Practice Address - Street 2:PINDAR PHYSICAL THERAPY INC
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201
Practice Address - Country:US
Practice Address - Phone:570-401-6566
Practice Address - Fax:570-501-2435
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC006277L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00298278OtherRAILROAD MEDICARE
PA089065Medicare ID - Type Unspecified