Provider Demographics
NPI:1205878428
Name:FAGAN, LINDA (NP)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:FAGAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 E OGLETHORPE HWY
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-1200
Mailing Address - Country:US
Mailing Address - Phone:912-876-2173
Mailing Address - Fax:912-368-8033
Practice Address - Street 1:1113 E OGLETHORPE HWY
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-1200
Practice Address - Country:US
Practice Address - Phone:912-876-2173
Practice Address - Fax:912-368-8033
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN101672363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000834897DMedicaid