Provider Demographics
NPI:1730377219
Name:FAGAN, JASON CURTIS
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:CURTIS
Last Name:FAGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-4022
Mailing Address - Country:US
Mailing Address - Phone:423-342-6177
Mailing Address - Fax:
Practice Address - Street 1:405 ORCHARD RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-4022
Practice Address - Country:US
Practice Address - Phone:423-342-6177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN71626164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse