=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588879316
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FAWN S HOGAN M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2007
-----------------------------------------------------
Last Update Date | 06/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3551 ROGER BROOKE DR BLDG 3600
-----------------------------------------------------
City | FORT SAM HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-916-3216
-----------------------------------------------------
Fax | 210-916-3758
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 40 GALLERIA DR
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78257-1712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-378-0974
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 0101236982
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | 0101236982
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------