Provider Demographics
NPI:1275650426
Name:FUGATE, PHILLIP DWAYNE (PTA)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:DWAYNE
Last Name:FUGATE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2467 BEAVER CREEK LN
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-4101
Mailing Address - Country:US
Mailing Address - Phone:803-649-0446
Mailing Address - Fax:
Practice Address - Street 1:101 GRACE DR
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-9088
Practice Address - Country:US
Practice Address - Phone:864-679-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1067225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant