Basic Information
| Provider Information | |||||||||
| NPI: | 1568704302 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUGATE | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | LEA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DISMUKE | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | LEA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1201 HADLEY RD | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461581737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178311160 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1201 HADLEY RD | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461581737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178311160 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2013 | ||||||||
| LastUpdateDate: | 03/24/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207L00000X | 01078223A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.