Healthcare Provider Details

I. General information

NPI: 1275996894
Provider Name (Legal Business Name): ETOSHA C FEGAN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 SW SHEVLIN HIXON DR STE 101
BEND OR
97702-3189
US

IV. Provider business mailing address

143 SW SHEVLIN HIXON DR STE 101
BEND OR
97702-3189
US

V. Phone/Fax

Practice location:
  • Phone: 541-317-9747
  • Fax:
Mailing address:
  • Phone: 541-317-9747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4311-ATI
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: