Healthcare Provider Details

I. General information

NPI: 1134468218
Provider Name (Legal Business Name): CATHY RENEE FAGEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CATHY R EVANCHO PA

II. Dates (important events)

Enumeration Date: 02/08/2013
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E COUNTY LINE RD STE 101
GREENWOOD IN
46143-1070
US

IV. Provider business mailing address

701 E COUNTY LINE RD STE 101
GREENWOOD IN
46143-1070
US

V. Phone/Fax

Practice location:
  • Phone: 317-885-2860
  • Fax: 317-885-2869
Mailing address:
  • Phone: 317-885-2860
  • Fax: 317-885-2869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001493A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: