Provider Demographics
NPI:1851479364
Name:FAGAN, CECILIA MARGARET (PA)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:MARGARET
Last Name:FAGAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CECILIA
Other - Middle Name:
Other - Last Name:SHEEHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:39901 TRADITIONS DR
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48168-9493
Practice Address - Country:US
Practice Address - Phone:248-305-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002539363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant