Provider Demographics
NPI:1811596224
Name:FAGAN, MARTHA (FNP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:FAGAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:
Other - Last Name:ADSIT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 MERIDIAN CENTRE BLVD STE 320
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-3984
Mailing Address - Country:US
Mailing Address - Phone:315-552-7763
Mailing Address - Fax:
Practice Address - Street 1:300 MERIDIAN CENTRE BLVD STE 320
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-3984
Practice Address - Country:US
Practice Address - Phone:315-552-7763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY346047363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily