Basic Information
Provider Information | |||||||||
NPI: | 1306979786 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FAGAN | ||||||||
FirstName: | BRYAN | ||||||||
MiddleName: | IGNATIUS | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17 LEWIS CT | ||||||||
Address2: |   | ||||||||
City: | NORTH EAST | ||||||||
State: | MD | ||||||||
PostalCode: | 219012244 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4102876977 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 500 UPPER CHESAPEAKE DR | ||||||||
Address2: | EMERGENCY DEPT | ||||||||
City: | BEL AIR | ||||||||
State: | MD | ||||||||
PostalCode: | 210144324 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4436432000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/14/2007 | ||||||||
LastUpdateDate: | 09/25/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | C0002882 | MD | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.