Provider Demographics
NPI:1649993817
Name:FAGERNESS, TIMOTHY (CNP)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:FAGERNESS
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 E 52ND ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-5448
Mailing Address - Country:US
Mailing Address - Phone:605-359-8547
Mailing Address - Fax:
Practice Address - Street 1:911 E 20TH ST STE 300
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1045
Practice Address - Country:US
Practice Address - Phone:605-504-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP002523207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine