Provider Demographics
NPI:1063210789
Name:FAGIN, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:FAGIN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:FAGIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:1295 WALLACE RD NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-3007
Mailing Address - Country:US
Mailing Address - Phone:503-361-3949
Mailing Address - Fax:503-763-6444
Practice Address - Street 1:1295 WALLACE RD NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-3007
Practice Address - Country:US
Practice Address - Phone:503-361-3949
Practice Address - Fax:503-763-6444
Is Sole Proprietor?:No
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6307225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist