Provider Demographics
NPI:1205825775
Name:FAGAN, MARIAN FRANCES (MD)
Entity type:Individual
Prefix:
First Name:MARIAN
Middle Name:FRANCES
Last Name:FAGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1726 S BECKHAM
Mailing Address - Street 2:PATHOLOGY ASSOCIATES OF TYLER
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701
Mailing Address - Country:US
Mailing Address - Phone:903-593-0481
Mailing Address - Fax:903-592-0555
Practice Address - Street 1:1726 S BECKHAM
Practice Address - Street 2:PATHOLOGY ASSOCIATES OF TYLER
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701
Practice Address - Country:US
Practice Address - Phone:903-593-0481
Practice Address - Fax:903-592-0555
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3341207ZH0000X, 207ZP0102X
LAMD202158207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX106106102Medicaid
C67888Medicare UPIN
TX106106102Medicaid