Provider Demographics
NPI:1538635669
Name:FAGAN, AGNES (APN)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:FAGAN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 FISH POND RD
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-3047
Mailing Address - Country:US
Mailing Address - Phone:856-863-9999
Mailing Address - Fax:856-863-9666
Practice Address - Street 1:269 FISH POND RD
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-3047
Practice Address - Country:US
Practice Address - Phone:856-863-9999
Practice Address - Fax:856-863-9666
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00851200363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics