Provider Demographics
NPI:1861459216
Name:NAGATA, FRED HISAO (DPM)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:HISAO
Last Name:NAGATA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1191 E HERNDON
Mailing Address - Street 2:STE 101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3164
Mailing Address - Country:US
Mailing Address - Phone:559-435-3039
Mailing Address - Fax:559-435-1105
Practice Address - Street 1:1191 E HERNDON AVE
Practice Address - Street 2:STE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3164
Practice Address - Country:US
Practice Address - Phone:559-435-3039
Practice Address - Fax:559-435-1105
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2516213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E25160Medicaid
CA0503340001Medicare NSC
CAT11368Medicare UPIN
CA0503340002Medicare NSC