Provider Demographics
NPI:1316370224
Name:FAGAN, PATRICK DANIEL (DPT)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:DANIEL
Last Name:FAGAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 WALL ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-3539
Mailing Address - Country:US
Mailing Address - Phone:636-669-2345
Mailing Address - Fax:636-669-2344
Practice Address - Street 1:1551 WALL ST
Practice Address - Street 2:SUITE 110
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-3539
Practice Address - Country:US
Practice Address - Phone:636-669-2345
Practice Address - Fax:636-669-2344
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012037663225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist