Provider Demographics
NPI:1902262124
Name:FAGAN, MICHAEL BRENDAN (PA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:BRENDAN
Last Name:FAGAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 N DEAN RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830-4098
Mailing Address - Country:US
Mailing Address - Phone:334-826-1111
Mailing Address - Fax:334-321-0399
Practice Address - Street 1:665 N DEAN RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36830-4098
Practice Address - Country:US
Practice Address - Phone:334-826-1111
Practice Address - Fax:334-321-0399
Is Sole Proprietor?:No
Enumeration Date:2016-01-04
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.1112363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical