Provider Demographics
NPI:1841444098
Name:FAGAN, STACY LOUISE (PA)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:LOUISE
Last Name:FAGAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2512 N MERIDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-1035
Mailing Address - Country:US
Mailing Address - Phone:405-605-5415
Mailing Address - Fax:
Practice Address - Street 1:2512 N MERIDIAN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-1035
Practice Address - Country:US
Practice Address - Phone:405-605-5415
Practice Address - Fax:405-605-5310
Is Sole Proprietor?:No
Enumeration Date:2008-11-13
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1779363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical