Provider Demographics
NPI:1750527362
Name:FAGERNESS, CHRISTOPHER ROBERT (ATC)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:ROBERT
Last Name:FAGERNESS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-3755
Mailing Address - Country:US
Mailing Address - Phone:605-421-9835
Mailing Address - Fax:
Practice Address - Street 1:498 4TH AVE NE
Practice Address - Street 2:
Practice Address - City:SIOUX CENTER
Practice Address - State:IA
Practice Address - Zip Code:51250-1606
Practice Address - Country:US
Practice Address - Phone:712-722-6312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-02
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004382255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer