Provider Demographics
NPI:1649353541
Name:FAGIN, WAYNE (LMT)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:FAGIN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 13TH ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2650
Mailing Address - Country:US
Mailing Address - Phone:503-371-7655
Mailing Address - Fax:
Practice Address - Street 1:460 13TH ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2650
Practice Address - Country:US
Practice Address - Phone:503-371-7655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6031174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist