Healthcare Provider Details

I. General information

NPI: 1902262124
Provider Name (Legal Business Name): MICHAEL BRENDAN FAGAN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2016
Last Update Date: 02/09/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 N DEAN RD
AUBURN AL
36830-4098
US

IV. Provider business mailing address

665 N DEAN RD
AUBURN AL
36830-4098
US

V. Phone/Fax

Practice location:
  • Phone: 334-826-1111
  • Fax: 334-321-0399
Mailing address:
  • Phone: 334-826-1111
  • Fax: 334-321-0399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.1112
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: