Healthcare Provider Details

I. General information

NPI: 1942206180
Provider Name (Legal Business Name): WAYNE A FAGAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 05/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4141 S. STAPLES SUITE 300
CORPUS CHRISTI TX
78411-2929
US

IV. Provider business mailing address

4141 S. STAPLES SUITE 300
CORPUS CHRISTI TX
78411-2155
US

V. Phone/Fax

Practice location:
  • Phone: 361-882-5560
  • Fax: 361-882-6011
Mailing address:
  • Phone: 361-882-5560
  • Fax: 361-882-6011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number45D0913782
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberJ4105
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: