Provider Demographics
NPI:1710649835
Name:FAGAN, COLBY BRAY (NP)
Entity Type:Individual
Prefix:
First Name:COLBY
Middle Name:BRAY
Last Name:FAGAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 TREMONT ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-5538
Mailing Address - Country:US
Mailing Address - Phone:617-429-9200
Mailing Address - Fax:
Practice Address - Street 1:354 TREMONT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-5538
Practice Address - Country:US
Practice Address - Phone:617-426-9200
Practice Address - Fax:617-426-9201
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2325154363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics