Provider Demographics
NPI:1023113495
Name:FAGAN, LYNNE L (MD)
Entity type:Individual
Prefix:
First Name:LYNNE
Middle Name:L
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 1:4108 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20816-2665
Mailing Address - Country:US
Mailing Address - Phone:301-320-2809
Mailing Address - Fax:
Practice Address - Street 1:4108 MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20816-2665
Practice Address - Country:US
Practice Address - Phone:301-320-2809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101039676207R00000X
MDDO34054207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6043798Medicaid
510608M86Medicare PIN
E53251Medicare UPIN