Healthcare Provider Details

I. General information

NPI: 1336437367
Provider Name (Legal Business Name): PAUL EMANUEL FAGAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 HARTNESS RD
STATESVILLE NC
28677-3425
US

IV. Provider business mailing address

PO BOX 1845
STATESVILLE NC
28687-1845
US

V. Phone/Fax

Practice location:
  • Phone: 704-871-9818
  • Fax:
Mailing address:
  • Phone: 704-873-4277
  • Fax: 704-978-3549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-03452
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: