Provider Demographics
NPI:1710393616
Name:FAGBEMI, MARIAN (PA)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:
Last Name:FAGBEMI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11551 FOREST CENTRAL DR
Mailing Address - Street 2:STE 133
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-3915
Mailing Address - Country:US
Mailing Address - Phone:972-985-7988
Mailing Address - Fax:972-985-7989
Practice Address - Street 1:4001 W 15TH ST
Practice Address - Street 2:SUITE 280
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5841
Practice Address - Country:US
Practice Address - Phone:972-985-7988
Practice Address - Fax:972-985-7989
Is Sole Proprietor?:No
Enumeration Date:2014-07-11
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX340300805Medicaid