Healthcare Provider Details

I. General information

NPI: 1063646305
Provider Name (Legal Business Name): PAUL ANTHONY FAGAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2009
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 N WESTHAVEN DR
OSHKOSH WI
54904-7668
US

IV. Provider business mailing address

855 N WESTHAVEN DR
OSHKOSH WI
54904-7668
US

V. Phone/Fax

Practice location:
  • Phone: 920-303-8700
  • Fax: 920-303-8801
Mailing address:
  • Phone: 920-303-8700
  • Fax: 920-303-8801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5101018111
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number63870-021
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: