Provider Demographics
NPI:1043900590
Name:FAGAN, KAITLYN MICHELLE (PA)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MICHELLE
Last Name:FAGAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1550 RIVERSIDE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4162
Mailing Address - Country:US
Mailing Address - Phone:904-923-6647
Mailing Address - Fax:904-355-7788
Practice Address - Street 1:1550 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4161
Practice Address - Country:US
Practice Address - Phone:904-923-6647
Practice Address - Fax:904-355-7788
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2025-02-13
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant