Healthcare Provider Details

I. General information

NPI: 1376339895
Provider Name (Legal Business Name): PATRICK FAGAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 08/27/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 STANTONSBURG RD
GREENVILLE NC
27834-2818
US

IV. Provider business mailing address

10 E FIELD ST
NEWNAN GA
30263-2206
US

V. Phone/Fax

Practice location:
  • Phone: 770-733-2177
  • Fax:
Mailing address:
  • Phone: 770-733-2177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberFAGA-I0ZYF7
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: