Provider Demographics
NPI:1962091850
Name:FAGAN, VINCENT ALAN
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:ALAN
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 1:371 CABANA BLVD W APT 107
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36609-1610
Mailing Address - Country:US
Mailing Address - Phone:765-719-1800
Mailing Address - Fax:
Practice Address - Street 1:371 CABANA BLVD W APT 107
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-1610
Practice Address - Country:US
Practice Address - Phone:765-719-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program