Provider Demographics
NPI:1750323770
Name:KAGAN, MARC (PA-C)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:KAGAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 90
Mailing Address - Street 2:INTERSECTION U.S. HWYS. 70 & 81
Mailing Address - City:WAURIKA
Mailing Address - State:OK
Mailing Address - Zip Code:73573
Mailing Address - Country:US
Mailing Address - Phone:580-228-2344
Mailing Address - Fax:
Practice Address - Street 1:1104 6TH STREET
Practice Address - Street 2:
Practice Address - City:RYAN
Practice Address - State:OK
Practice Address - Zip Code:73565
Practice Address - Country:US
Practice Address - Phone:580-757-2451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA-2006-0006363AM0700X
OK956363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK347619301Medicare PIN
S82883Medicare UPIN