Provider Demographics
NPI:1053193565
Name:FAGAN, TODD ALLEN
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:ALLEN
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 1:1845 FAIRMOUNT ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67260-0018
Mailing Address - Country:US
Mailing Address - Phone:316-978-5575
Mailing Address - Fax:316-978-3177
Practice Address - Street 1:1845 FAIRMOUNT ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67260-0018
Practice Address - Country:US
Practice Address - Phone:316-978-5575
Practice Address - Fax:316-978-3177
Is Sole Proprietor?:No
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-005072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer