Healthcare Provider Details

I. General information

NPI: 1043900590
Provider Name (Legal Business Name): KAITLYN MICHELLE FAGAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2023
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 RIVERSIDE AVE
JACKSONVILLE FL
32204-4161
US

IV. Provider business mailing address

1550 RIVERSIDE AVE STE A
JACKSONVILLE FL
32204-4162
US

V. Phone/Fax

Practice location:
  • Phone: 904-923-6647
  • Fax: 904-355-7788
Mailing address:
  • Phone: 904-923-6647
  • Fax: 904-355-7788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: