Provider Demographics
NPI:1447784301
Name:FAGAN, WILLIAM SHAWN (RN)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:SHAWN
Last Name:FAGAN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 SNOWHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-1634
Mailing Address - Country:US
Mailing Address - Phone:937-450-3522
Mailing Address - Fax:
Practice Address - Street 1:816 SNOWHILL BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-1634
Practice Address - Country:US
Practice Address - Phone:937-450-3522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.147539.MEDS-IV164W00000X
OHRN.437732163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse