Provider Demographics
NPI:1356066112
Name:FUGATE, CAROLINE MACKENZIE (PA-C)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:MACKENZIE
Last Name:FUGATE
Suffix:
Gender:F
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 1:920 WESTCOTT ST APT 240
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-5684
Mailing Address - Country:US
Mailing Address - Phone:214-952-1637
Mailing Address - Fax:
Practice Address - Street 1:6701 FANNIN ST STE 1210
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2612
Practice Address - Country:US
Practice Address - Phone:832-824-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA15955363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA15955OtherTEXAS PHYSICIAN ASSISTANT LICENSE NUMBER