Provider Demographics
NPI:1275639098
Name:FAGEN, LEE MARSHALL (NP)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:MARSHALL
Last Name:FAGEN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 HILLEGASS AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-1206
Mailing Address - Country:US
Mailing Address - Phone:510-843-5326
Mailing Address - Fax:
Practice Address - Street 1:2222 BANCROFT EXT
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-4303
Practice Address - Country:US
Practice Address - Phone:510-643-9135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN373234, NP7501363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health