Individual
JAKE FAGAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1055 N 500 W # 111, PROVO, UT 84604-3305
(801) 374-8999
Mailing address
1055 N 500 W, ATT CREDENTIALING, PROVO, UT 84604
(801) 354-8225
(801) 418-0941
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
MED-PHYS-LIC-76211
MT
207ND0101X
MOHS-Micrographic Surgery Physician
Primary
6845592-1205
UT
207ND0101X
MOHS-Micrographic Surgery Physician
76211
MT
207ND0101X
MOHS-Micrographic Surgery Physician
MED-PHYS-LIC-76211
MT
2086X0206X
Surgical Oncology Physician
MED-PHYS-LIC-76211
MT
390200000X
Student in an Organized Health Care Education/Training Program
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Other
Enumeration date
04/02/2014
Last updated
04/17/2024
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