Provider Demographics
NPI:1275996894
Name:FEGAN, ETOSHA C (OD)
Entity Type:Individual
Prefix:
First Name:ETOSHA
Middle Name:C
Last Name:FEGAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 SW SHEVLIN HIXON DR STE 101
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3189
Mailing Address - Country:US
Mailing Address - Phone:541-317-9747
Mailing Address - Fax:
Practice Address - Street 1:143 SW SHEVLIN HIXON DR STE 101
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3189
Practice Address - Country:US
Practice Address - Phone:541-317-9747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-31
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4311-ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist