Provider Demographics
NPI:1558572735
Name:FAGERSTROM, PAUL (PT)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:FAGERSTROM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 SHEFFIELD LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-3318
Mailing Address - Country:US
Mailing Address - Phone:856-722-0878
Mailing Address - Fax:856-380-1365
Practice Address - Street 1:1403 SHIRLEY LN
Practice Address - Street 2:
Practice Address - City:PERKASIE
Practice Address - State:PA
Practice Address - Zip Code:18944-2868
Practice Address - Country:US
Practice Address - Phone:215-453-0615
Practice Address - Fax:215-453-2076
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT000805E225100000X
DEJ1-0001848225100000X
NJ40QA00230700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist