Provider Demographics
NPI:1598878431
Name:FAGAN, THOMAS (PT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:FAGAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6100
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-6100
Mailing Address - Country:US
Mailing Address - Phone:505-424-0134
Mailing Address - Fax:505-424-1299
Practice Address - Street 1:2954 RODEO PARK DR W
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6351
Practice Address - Country:US
Practice Address - Phone:505-424-0131
Practice Address - Fax:505-424-1299
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM#430261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN4536Medicaid
NMN4536Medicaid