Provider Demographics
NPI:1609693852
Name:FAGERSTROM, KARA ROSE (PAC)
Entity type:Individual
Prefix:
First Name:KARA
Middle Name:ROSE
Last Name:FAGERSTROM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3151 WALBERT AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-6042
Mailing Address - Country:US
Mailing Address - Phone:484-526-1735
Mailing Address - Fax:484-526-2429
Practice Address - Street 1:3151 WALBERT AVE STE 200
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-6042
Practice Address - Country:US
Practice Address - Phone:484-526-1735
Practice Address - Fax:484-526-2429
Is Sole Proprietor?:No
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA065979363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant