Healthcare Provider Details

I. General information

NPI: 1265448500
Provider Name (Legal Business Name): SHAWN P FAGAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3675 J DEWEY GRAY CIR STE. 300
AUGUSTA GA
30909-1868
US

IV. Provider business mailing address

PO BOX 3726
AUGUSTA GA
30914-3726
US

V. Phone/Fax

Practice location:
  • Phone: 706-863-9595
  • Fax: 888-745-3917
Mailing address:
  • Phone: 706-863-9595
  • Fax: 888-745-3917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberMD37935
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberK5294
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number0101268805
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number73150
License Number StateGA
# 5
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number73150
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: