Provider Demographics
NPI:1063627297
Name:FAGHAN, BRIAN M (PTA)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:M
Last Name:FAGHAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 LONG POND RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-2642
Mailing Address - Country:US
Mailing Address - Phone:508-746-6922
Mailing Address - Fax:508-746-7211
Practice Address - Street 1:110 LONG POND RD
Practice Address - Street 2:SUITE 111
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-2642
Practice Address - Country:US
Practice Address - Phone:508-746-6922
Practice Address - Fax:508-746-7211
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6208225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant