Healthcare Provider Details

I. General information

NPI: 1871572578
Provider Name (Legal Business Name): MARY L FEAGANS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 10/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

IV. Provider business mailing address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

V. Phone/Fax

Practice location:
  • Phone: 601-268-5800
  • Fax: 601-261-3530
Mailing address:
  • Phone: 601-268-5800
  • Fax: 601-261-3530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00165
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA200038
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: