Healthcare Provider Details

I. General information

NPI: 1407907454
Provider Name (Legal Business Name): KATHLEEN M. REAGAN P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 02/03/2020
Certification Date: 02/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 HAY ST
FAYETTEVILLE NC
28305-5312
US

IV. Provider business mailing address

806 HAY ST
FAYETTEVILLE NC
28305-5312
US

V. Phone/Fax

Practice location:
  • Phone: 910-860-7008
  • Fax: 910-221-9006
Mailing address:
  • Phone: 910-860-7008
  • Fax: 910-221-9006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number100973
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: