Provider Demographics
NPI:1134468218
Name:FAGEN, CATHY RENEE (PA-C)
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:RENEE
Last Name:FAGEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CATHY
Other - Middle Name:R
Other - Last Name:EVANCHO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 7112
Mailing Address - Street 2:DEPT 31
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46207-7112
Mailing Address - Country:US
Mailing Address - Phone:317-528-5261
Mailing Address - Fax:317-528-5026
Practice Address - Street 1:8111 S EMERSON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8601
Practice Address - Country:US
Practice Address - Phone:317-528-5261
Practice Address - Fax:317-528-5026
Is Sole Proprietor?:No
Enumeration Date:2013-02-08
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001493A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN339250003Medicare PIN