Provider Demographics
NPI:1003479254
Name:FAGAN, KILEY KATHERINE (MD)
Entity Type:Individual
Prefix:
First Name:KILEY
Middle Name:KATHERINE
Last Name:FAGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 ARONSON LAKE CT
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-7172
Mailing Address - Country:US
Mailing Address - Phone:770-296-3795
Mailing Address - Fax:
Practice Address - Street 1:775 ARONSON LAKE CT
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-7172
Practice Address - Country:US
Practice Address - Phone:770-296-3795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10808207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10808Medicaid