Basic Information
| Provider Information | |||||||||
| NPI: | 1891899910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUGAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 740 S LIMESTONE | ||||||||
| Address2: | A-301 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405360284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593236494 | ||||||||
| FaxNumber: | 8592574682 | ||||||||
| Practice Location | |||||||||
| Address1: | 740 S LIMESTONE | ||||||||
| Address2: | A-301 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405360284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593236494 | ||||||||
| FaxNumber: | 8592574682 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 06/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA446 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | PA446 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA446 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 95004602 | 05 | KY | MEDICAID |