Provider Demographics
NPI:1033423496
Name:FAGAN, ASHLEY JANAE (DO)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:JANAE
Last Name:FAGAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:JANAE
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1280 S MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-7509
Mailing Address - Country:US
Mailing Address - Phone:817-310-0898
Mailing Address - Fax:817-310-5524
Practice Address - Street 1:1280 S MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-7509
Practice Address - Country:US
Practice Address - Phone:817-310-0898
Practice Address - Fax:817-310-5524
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN7802207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX323095501Medicaid
TX297032YKPWMedicare PIN