Provider Demographics
NPI:1942206180
Name:FAGAN, WAYNE A (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:A
Last Name:FAGAN
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 1:4141 S. STAPLES SUITE 300
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-2155
Mailing Address - Country:US
Mailing Address - Phone:361-882-5560
Mailing Address - Fax:361-882-6011
Practice Address - Street 1:4141 S. STAPLES SUITE 300
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-2929
Practice Address - Country:US
Practice Address - Phone:361-882-5560
Practice Address - Fax:361-882-6011
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D0913782207ND0900X
TXJ4105207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86470YOtherBLUE CROSS
TX0040EEOtherBLUE CROSS BLUE SHIELD
TX080856001Medicaid
TX070017610OtherMEDICARE RAILROAD
TX1356536494OtherGROUP NPI #
TXCK7292OtherMEDICARE RAILROAD
TXG08046Medicare UPIN
TX86470YOtherBLUE CROSS