Provider Demographics
NPI:1992757504
Name:FAGAN, HEATHER ANN (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:FAGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:A
Other - Last Name:CHRISTIANSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:602-651-4945
Practice Address - Street 1:13535 NEMOURS PKWY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7402
Practice Address - Country:US
Practice Address - Phone:407-650-7000
Practice Address - Fax:407-567-5924
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107219208000000X, 2080P0203X
FLME1203082080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics