1942206180 NPI number — DR. WAYNE A FAGAN M.D.

Table of content: DR. WAYNE A FAGAN M.D. (NPI 1942206180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942206180 NPI number — DR. WAYNE A FAGAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAGAN
Provider First Name:
WAYNE
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942206180
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4141 S. STAPLES SUITE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORPUS CHRISTI
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78411-2155
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-882-5560
Provider Business Mailing Address Fax Number:
361-882-6011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4141 S. STAPLES SUITE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORPUS CHRISTI
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78411-2929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-882-5560
Provider Business Practice Location Address Fax Number:
361-882-6011
Provider Enumeration Date:
06/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207ND0900X , with the licence number:  45D0913782 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ND0101X , with the licence number: J4105 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 86470Y . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0040EE . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 080856001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 070017610 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1356536494 . This is a "GROUP NPI #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: CK7292 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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