Provider Demographics
NPI:1831187798
Name:LINDA R. FAGAN, INC.
Entity type:Organization
Organization Name:LINDA R. FAGAN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:FAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP, PHD
Authorized Official - Phone:305-246-8224
Mailing Address - Street 1:45 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-5941
Mailing Address - Country:US
Mailing Address - Phone:305-246-8224
Mailing Address - Fax:305-246-8556
Practice Address - Street 1:45 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-5941
Practice Address - Country:US
Practice Address - Phone:305-246-8224
Practice Address - Fax:305-246-8556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL647292363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS09059Medicare UPIN
FLY4049AMedicare ID - Type Unspecified