Provider Demographics
NPI:1609813807
Name:FUGATE, SHAWN SHADELL (MD)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:SHADELL
Last Name:FUGATE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 W KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40977-1343
Mailing Address - Country:US
Mailing Address - Phone:606-337-3223
Mailing Address - Fax:
Practice Address - Street 1:313 S CHERRY ST
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:KY
Practice Address - Zip Code:40977-1724
Practice Address - Country:US
Practice Address - Phone:606-654-3338
Practice Address - Fax:606-654-2273
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY26778207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000068941OtherBLUE CROSS
KY64267784Medicaid
KY000000068941OtherBLUE CROSS
KY64267784Medicaid