Provider Demographics
NPI:1548423817
Name:FAGAN, LANDREY (MD)
Entity Type:Individual
Prefix:
First Name:LANDREY
Middle Name:
Last Name:FAGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 MOUNTAIN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3129
Mailing Address - Country:US
Mailing Address - Phone:303-651-5111
Mailing Address - Fax:303-678-4050
Practice Address - Street 1:1950 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3129
Practice Address - Country:US
Practice Address - Phone:303-651-5111
Practice Address - Fax:303-678-4050
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA246674207Q00000X
CODR.0060345207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine