Individual
MARIE LOUISE FAGAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
IDC
Contact information
Practice address
4077 32ND ST, APT 8, SAN DIEGO, CA 92104-2080
(678) 764-4067
Mailing address
4077 32ND ST, APT 8, SAN DIEGO, CA 92104-2080
(678) 764-4067
Taxonomy
Speciality
Code
Description
License number
State
171000000X
Military Health Care Provider
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1710-1002X
IDC
—
Enumeration date
05/09/2013
Last updated
05/09/2013
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