Provider Demographics
NPI:1174682074
Name:FUGATE, BRYAN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:FUGATE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2822 COLONY POINTE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41102
Mailing Address - Country:US
Mailing Address - Phone:606-325-9537
Mailing Address - Fax:
Practice Address - Street 1:6900 WEST COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705
Practice Address - Country:US
Practice Address - Phone:304-733-1060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT25336225X00000X
225XR0403X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XR0403XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistDriving and Community Mobility
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7502079000Medicaid