Provider Demographics
NPI:1548688989
Name:FAGAN, JAKE (MD)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:FAGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATT CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1055 N 500 W # 111
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-374-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PHYS-LIC-76211207N00000X, 207ND0101X, 2086X0206X
MT76211207ND0101X
390200000X
UT6845592-1205207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program