Provider Demographics
NPI:1417976143
Name:FAGAN, WILLIAM (DC)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:FAGAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2180 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1666
Mailing Address - Country:US
Mailing Address - Phone:808-242-6464
Mailing Address - Fax:808-984-7442
Practice Address - Street 1:2180 MAIN ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1666
Practice Address - Country:US
Practice Address - Phone:808-242-6464
Practice Address - Fax:808-984-7442
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDC163111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI54551901Medicaid
HI235226OtherHMSA - 65CP - HMSA QUEST
HI990176859OtherHMAA
HI54551901Medicaid
HIT04851Medicare UPIN
HI350054897Medicare ID - Type UnspecifiedRAILROAD MEDICARE